Pediatric Informatics: Computer Applications in Child Health (Health ...

370 M. Apkon
Fig. 29.1 Hazards and harm
DANGER
of actions by individuals. Although errors may well contribute to system failures,
not all failures are caused by errors.
The risks of errors being committed or other failures occurring are examples
of dangers or hazards in the environment that can contribute to harm or other
undesirable effects. James Reason is an organizational safety expert who has developed
a useful and widely used model relating these hazards to harm. 2 In Reason’s
model (Fig. 29.1), hazards are an inevitable property of our systems. Organizations
typically provide multiple layers of defenses that prevent, detect, or intercept
potential failures and provide a means of protecting the system from causing harm.
However, we must recognize that these defenses are incomplete. For example,
defenses might not be developed for certain hazards or they might not operate under
every possible condition. When hazards are not intercepted, there is the potential to
cause harm or loss and result in, what Reason terms, an accident.
This model of accident causation suggests three broad strategies for system
improvement: (1) eliminating hazards; (2) elevating defenses; and, (3) ensuring
rescue should an accident occur. Improvement requires not only an awareness that
errors, failures, and accidents occur, but also an understanding of how they occur
and a mechanism to evaluate and prioritize potential countermeasures.
These strategies can be incorporated into information systems to prevent failures
of those systems. Additionally, information systems can be used as mechanisms to
implement each of these strategies in reducing failures for other systems.
29.3 Root Cause Analysis
Hazards
Defenses
Harm Rescue
Eliminate Elevate Ensure
Preventing recurrent failure requires identifying the underlying cause or causes.
The ability to look back on a sequence of events and discern the factors that led
away from the desired outcome seems straightforward in the light of knowing how
things turned out. However, investigators are biased by knowing the outcomes,
an effect known as hindsight bias. 3 Hindsight bias causes investigators to see the
sequence of events as occurring under conditions where trajectories could be predicted.
Investigators also are prone to working back from the point of failure and
identifying the closest contributor without regard to any number of contributing
factors and conditions. Root Cause Analysis (RCA) refers to a structured approach
to investigation in order to avoid these and other biases in defining the contributors
to failure. The purpose of RCA is to determine: what happened; why it happened;
and what countermeasures could be developed to prevent recurrence.