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

29 Understanding and Preventing Errors 381
29.8 Conclusion
Healthcare delivery is a complex process requiring the coordinated action of many
actors, movement of information across time and space, and decision making in the
face of frequent uncertainty. Given this complexity, it is not surprising that errors and
failures occur. At the same time, we are compelled to do better. Improving the safety
and effectiveness of care requires us to understand the processes used to deliver
care and the ways that they fail to achieve their desired objectives. Disciplined
approaches to root cause analysis facilitate developing a deeper understanding
and avoiding the hindsight bias that otherwise may truncate the investigation prematurely.
When processes are at risk for repeated failure, failure mode and effects
analysis can help one to understand the contributors to risk across multiple failure
points. FMEA helps focus the development of countermeasures where they may
have the greatest impact.
Just as structuring the analysis of failures using RCA and FMEA can optimize
learning, disciplined error-proofing techniques can optimize solution finding and
accelerate the trajectory of improvement. Eliminating hazards, elevating defenses,
and ensuring rescue are general strategies that work together to prevent harm in
error-prone systems.
The import and impact of the problems we seek to solve together with a lack
of familiarity with the tools described above can intimidate some individuals and
teams from embarking on a structured improvement journey. This, coupled with the
desire for quick action can lead to identifying and apparently rectifying the most
easily identifiable “cause” although this approach is less likely to result in reducing
the likelihood or impact of future failure. It is a mistake to assume that the tools
described here are applicable only for certain types of failures, are applied only by
interdisciplinary teams, or must take extended periods of time. Rather, these tools
are intended to guide thinking across a wide range of error situations and are helpful
to individuals or teams. Perhaps the best way to gain familiarity with this way
of thinking is to simply jump in.
References
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