PNNL

Abstract

It is no secret that healthcare, in general, has become an increasingly complicated mixture of technical systems, complex processes and intricate skilled human interactions. Patient care processes have followed this same trend. The healthcare industry, itself, has acknowledged that it is fraught with high-risk and error prone processes and cite medication management systems, invasive procedures and diagnostic methods. Complexity represents opportunity for unanticipated events, process failures and undesirable outcomes. Traditionally when a patient care process fails, accountability was focused on the individual clinician error. However, increasing, healthcare is following the lead of other high-risk industries (e.g. chemical, aerospace, nuclear, etc.) that give attention to the characteristics the overall system that contribute to the failure. The focus has shifted to identification of systemic weaknesses and vulnerabilities. Increasing the healthcare industry is using prospective system assessment methods to evaluate the high-risk systems and processes. This paper describes results of collaboration between engineers and community hospitals in Southwest Washington State between 2002 and 2007 in applying prospective system assessment methods to a range of the high-risk healthcare systems and processes. This includes the use of Failure Mode Effects and Criticality Analysis and Probabilistic Risk Assessment. It includes assessing such healthcare processes as medication delivery, blood transfusion, inter-hospital transfer of emergency patients and the management of mental health patients in a medical setting. This paper presents two case studies: 1) an inter-hospital FMEA on patient transfer and 2) a risk assessment of mental health patients who present themselves in a hospital Emergency Department.