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

29 Understanding and Preventing Errors 373
List 29.1 Cause and effect
Machines
� IV pumps cannot detect the strength of the formulation they are infusing
Materials
� The correct cassette of morphine was not available
Methods
� Reordering of medication does not occur until the next dose is required
Measurements
� The unit of measurement for the IV pump is based on volume infused rather
than the dose administered
Mother-nature (environment)
� Noise contributed to distraction at the time the nurse was checking
People
� Nurse was incompletely trained
� No second nurse was available to cross-check the IV pump settings
Other structured approached to RCA rely on formal sets of questions intended
to examine specific possible causes. The National Center for Patient Safety of
the Veteran’s Affairs Administration has developed a set of Triage Cards 6 that
provide a series of questions to explore causes and conditions related to: training;
communication; staff fatigue; environmental factors; rules and policies; and, failures
of barriers or controls. These questions serve as an alternative to the Five-Why
approach and ensure a broad scope for investigation. The questions follow a logical
thread where affirmative answers prompt a deeper level of questioning.
The relationships between causes, conditions, and effects can be displayed
graphically in order to clarify the relationships. Logical relationships can be developed
and tested for consistency in explaining the chain and the ultimate effect to be
investigated. 5,7 This helps ensure a comprehensive analysis and may help identify
causes or conditions which may be altered to prevent recurrence.
29.4 Failure Mode and Effects Analysis
Root Cause Analysis can be helpful in identifying holes in defenses and risk points
only after a failure or near miss has occurred. Moreover, each RCA presents one
view of failure and no specific way of aggregating or integrating experiences
over time. Nor does RCA provide an approach to prospective risk identification
and reduction. Failure Mode and Effects Analysis (FMEA) provides an approach
to understanding the riskiest components of processes in order to prioritize the
development of countermeasures. FMEA can be used prospectively to identify risk
points, can be used as a way to integrate information across RCAs, and can be used
to compare the relative riskiness of alternative process designs.
FMEA is a tool developed by reliability experts and used in a number of
industries to systematically evaluate complex processes with respect to the types