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Articles

Design for patient safety: a systems-based risk identification framework

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Pages 1046-1064 | Received 19 Aug 2017, Accepted 31 Jan 2018, Published online: 15 Feb 2018

References

  • Ashley, L., and G. Armitage. 2010. “Failure Mode and Effects Analysis: An Empirical Comparison of Failure Mode Scoring Procedures.” Journal of Patient Safety 6: 210–215. doi:10.1097/PTS.0b013e3181fc98d7.
  • Bates, D. W., M. Cohen, L. L. Leape, J. M. Overhage, M. M. Shabot, and T. Sheridan. 2001. “Reducing the Frequency of Errors in Medicine Using Information Technology.” Journal of the American Medical Informatics Association 8: 299–308.10.1136/jamia.2001.0080299
  • Breakwell, G. M., S. Hammond, C. Fife-Schaw. 2000. Research Methods in Psychology. Los Angeles, CA: SAGE Publications Ltd.
  • Carayon, P., A. Schoofs Hundt, B.-T. Karsh, A. P. Gurses, C. J. Alvarado, M. Smith, and P. Flatley Brennan. 2006. “Work System Design for Patient Safety: The SEIPS Model.” Quality and Safety in Health Care 15 (Suppl_1): i50–i58. doi:10.1136/qshc.2005.015842.
  • Carayon, P., T. B. Wetterneck, A. J. Rivera-Rodriguez, A. S. Hundt, P. Hoonakker, R. Holden, and A. P. Gurses. 2014. “Human Factors Systems Approach to Healthcare Quality and Patient Safety.” Applied Ergonomics 45: 14–25. doi:10.1016/j.apergo.2013.04.023.
  • Card, A. J., J. R. Ward, and P. J. Clarkson. 2012. “Beyond FMEA: The Structured What-If Technique (SWIFT).” Journal of Healthcare Risk Management 31: 23–29. doi:10.1002/jhrm.20101.
  • Card, A. J., M. C. E. Simsekler, M. Clark, J. R. Ward, and P. J. Clarkson. 2014. “Use of the Generating Options for Active Risk Control (GO-ARC) Technique Can Lead to More Robust Risk Control Options.” The International Journal of Risk & Safety in Medicine 26: 199–211. doi:10.3233/JRS-140636.
  • Chiozza, M. L., and C. Ponzetti. 2009. “FMEA: A Model for Reducing Medical Errors.” Clinica Chimica Acta 404: 75–78. doi:10.1016/j.cca.2009.03.015.
  • Clarkson, P.J., J. R. Ward, P. Buckle, J. Berman. 2010. Prospective Hazard Analysis Toolkit (No. 978-0-9545243-4–0). Cambridge: University of Cambridge.
  • Classen, D. C., R. Resar, F. Griffin, F. Federico, T. Frankel, N. Kimmel, J. C. Whittington, A. Frankel, A. Seger, and B. C. James. 2011. “‘Global Trigger Tool’ Shows That Adverse Events in Hospitals May Be Ten times Greater than Previously Measured.” Health Affairs 30: 581–589. doi:10.1377/hlthaff.2011.0190.
  • Ericson, C. A. 2005. Hazard Analysis Techniques for System Safety. Hoboken, NJ: Wiley-Blackwell.10.1002/0471739421
  • Franklin, B. D., N. A. Shebl, and N. Barber. 2012. “Failure Mode and Effects Analysis: Too Little for Too Much?.” BMJ Quality & Safety 21: 607–611. doi:10.1136/bmjqs-2011-000723.
  • Gurses, A. P., A. A. Ozok, and P. J. Pronovost. 2012. “Time to Accelerate Integration of Human Factors and Ergonomics in Patient Safety: Table 1.” BMJ Quality & Safety 21: 347–351. doi:10.1136/bmjqs-2011-000421.
  • Hettinger, L. J., A. Kirlik, Y. M. Goh, and P. Buckle. 2015. “Modelling and Simulation of Complex Sociotechnical Systems: Envisioning and Analysing Work Environments.” Ergonomics 58: 600–614. doi:10.1080/00140139.2015.1008586.
  • Hignett, S., and J. Lu. 2010. “Space to Care and Treat Safely in Acute Hospitals: Recommendations from 1866 to 2008.” Applied Ergonomics 41: 666–673. doi:10.1016/j.apergo.2009.12.010.
  • Hignett, S., P. Griffiths, G. Sands, L. Wolf, and E. Costantinou. 2013. “Patient Falls: Focusing on Human Factors rather than Clinical Conditions.” Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care 2: 99–104. doi:10.1177/2327857913021019.
  • Hudson, D. W., C. G. Holzmueller, P. J. Pronovost, S. J. Gianci, Z. T. Pate, J. Wahr, E. S. Heitmiller, D. A. Thompson, E. A. Martinez, J. A. Marsteller, A. P. Gurses, L. H. Lubomski, C. A. Goeschel, and J. C. Pham. 2012. “Toward Improving Patient Safety through Voluntary Peer-to-Peer Assessment.” American Journal of Medical Quality 27: 201–209. doi:10.1177/1062860611421981.
  • IOM. 2000. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press.
  • ISO 31000. 2008. ISO 31000:2009 – Risk Management – Principles and Guidelines. Geneva: The International Organization for Standardization.
  • James, J. T. 2013. “A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care.” Journal of Patient Safety 9: 122–128. doi:10.1097/PTS.0b013e3182948a69.
  • Joseph, A., S. Bayramzadeh, Z. Zamani, and B. Rostenberg. 2017. “Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review.” HERD 1937586717705107. doi:10.1177/1937586717705107.
  • Jun, G. T., A. Canham, A. Altuna-Palacios, J. R. Ward, R. Bhamra, S. Rogers, A. Dutt, and P. Shah. 2017. “A Participatory Systems Approach to Design for Safer Integrated Medicine Management.” Ergonomics 61: 48–68. doi:10.1080/00140139.2017.1329939.
  • Kessels-Habraken, M., T. Van der Schaaf, J. De Jonge, C. Rutte, and K. Kerkvliet. 2009. “Integration of Prospective and Retrospective Methods for Risk Analysis in Hospitals.” International Journal for Quality in Health Care 21: 427–432. doi:10.1093/intqhc/mzp043.
  • Kurutkan, M. N., E. Usta, F. Orhan, and M. C. E. Simsekler. 2015. “Application of the IHI Global Trigger Tool in Measuring the Adverse Event Rate in a Turkish Healthcare Setting.” The International Journal of Risk & Safety in Medicine 27: 11–21. doi:10.3233/JRS-150639.
  • Leape, L. L., and D. M. Berwick. 2005. “Five Years after to Err is Human: What Have We Learned?.” JAMA 293: 2384–2390. doi:10.1001/jama.293.19.2384.
  • Linkin, D. R., C. Sausman, L. Santos, C. Lyons, C. Fox, L. Aumiller, J. Esterhai, B. Pittman, and E. Lautenbach. 2005. “Applicability of Healthcare Failure Mode and Effects Analysis to Healthcare Epidemiology: Evaluation of the Sterilization and Use of Surgical Instruments.” Clinical Infectious Diseases An official Publication of the Infectious Disesases Scoiety of America 41: 1014–1019. doi:10.1086/433190.
  • Lyons, M. 2009. “Towards a Framework to Select Techniques for Error Prediction: Supporting Novice Users in the Healthcare Sector.” Applied Ergonomics 40: 379–395. doi:10.1016/j.apergo.2008.11.004.
  • Maben, J., P. Griffiths, C. Penfold, M. Simon, J. E. Anderson, G. Robert, E. Pizzo, J. Hughes, T. Murrells, and J. Barlow. 2016. “One Size Fits All? Mixed Methods Evaluation of the Impact of 100% Single-Room Accommodation on Staff and Patient Experience, Safety and Costs.” BMJ Quality & Safety 25: 241–256. doi:10.1136/bmjqs-2015-004265.
  • Nielsen, J., 1993. Usability Engineering. 1st ed. Boston, MA: Morgan Kaufmann.
  • NPSA. 2009. Root Cause Analysis Investigation Tools Contributory Factors Classification Framework. Redditch: NPSA.
  • Pati, D., S. Pati, and T. E. Harvey. 2016. “Security Implications of Physical Design Attributes in the Emergency Department.” HERD: Health Environments Research & Design Journal 9: 50–63. doi:10.1177/1937586715626549.
  • Potts, H. W., J. E. Anderson, L. Colligan, P. Leach, S. Davis, and J. Berman. 2014. “Assessing the Validity of Prospective Hazard Analysis Methods: A Comparison of Two Techniques.” BMC Health Services Research 14: 206. doi:10.1186/1472-6963-14-41.
  • Rogers, S. 2002. “A Structured Approach for the Investigation of Clinical Incidents in Health Care: Application in a General Practice Setting.” British Journal of General Practice 52: S30–S32.
  • Runciman, W. B., J. A. H. Williamson, A. Deakin, K. A. Benveniste, K. Bannon, and P. D. Hibbert. 2006. “An Integrated Framework for Safety, Quality and Risk Management: An Information and Incident Management System Based on a Universal Patient Safety Classification.” Quality and Safety in Health Care 15: i82–i90. doi:10.1136/qshc.2005.017467.
  • Sari, A. B.-A., T. A. Sheldon, A. Cracknell, and A. Turnbull. 2007. “Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital: Retrospective Patient Case Note Review.” BMJ 334: 79. doi:10.1136/bmj.39031.507153.AE.
  • Shebl, N. A., B. D. Franklin, and N. Barber. 2009. “Is Failure Mode and Effect Analysis Reliable?” Journal of Patient Safety 5: 86–94. doi:10.1097/PTS.0b013e3181a6f040.
  • Shebl, N., B. Franklin, N. Barber, S. Burnett, and A. Parand. 2012. “Failure Mode and Effects Analysis: Views of Hospital Staff in the UK.” Journal of Health Services Research & Policy 17: 37–43. doi:10.1258/jhsrp.2011.011031.
  • Shebl, N. A., B. D. Franklin, and N. Barber. 2012. “Failure Mode and Effects Analysis Outputs: Are They Valid?” BMC Health Services Research 12: 1555. doi:10.1186/1472-6963-12-150.
  • Simsekler, M. C. E. 2015. Design for Patient Safety: A Systems-Based Risk Identification Framework. Cambridge: University of Cambridge.
  • Simsekler, M. C. E., A. J. Card, K. Ruggeri, J. R. Ward, and P. J. Clarkson. 2015a. “A Comparison of the Methods Used to Support Risk Identification for Patient Safety in One UK NHS Foundation Trust.” Clinical Risk 21: 37–46. doi:10.1177/1356262215580224.
  • Simsekler, M. C. E., A. J. Card, J. R. Ward, and P. J. Clarkson. 2015b. “Trust-Level Risk Identification Guidance in the NHS East of England.” Int. J. Risk Saf. Med. 27: 67–76. doi:10.3233/JRS-150651.
  • Simsekler, M. C. E., J. R. Ward, and P. J. Clarkson. 2018. “Evaluation of System Mapping Approaches in Identifying Patient Safety Risks.” International Journal for Quality in Health Care 1–7: doi:10.1093/intqhc/mzx176.
  • Smith, B. E., H. H. de Jong, M. H. C. Everdij. 2008. “A Prognostic Method to Identify Hazards for Future Aviation Concepts.” Presented at the 26th International Congress of the Aeronautical Sciences, ICAS 2018, Alaska.
  • Taylor, E., and S. Hignett. 2016. “The SCOPE of Hospital Falls: A Systematic Mixed Studies Review.” HERD: Health Environments Research & Design Journal 9: 86–109. doi:10.1177/1937586716645918.
  • van Tilburg, C. M., I. P. Leistikow, C. M. A. Rademaker, M. B. Bierings, and A. T. H. van Dijk. 2006. “Health Care Failure Mode and Effect Analysis: A Useful Proactive Risk Analysis in a Pediatric Oncology Ward.” Quality and Safety in Health Care 15: 58–63. doi:10.1136/qshc.2005.014902.
  • Unbeck, M., K. Schildmeijer, P. Henriksson, U. Jürgensen, O. Muren, L. Nilsson, and K. Pukk Härenstam. 2013. “Is Detection of Adverse Events Affected by Record Review Methodology? An Evaluation of the “Harvard Medical Practice Study” Method and the “Global Trigger Tool”.” Patient Safety in Surgery 7: 10. doi:10.1186/1754-9493-7-10.
  • Wachter, R. M. 2004. “The End of the Beginning: Patient Safety Five Years after ‘to Err is Human’.” Health Affairs Project Hope Suppl Web Exclusives, W4-534–45. https://doi.org/10.1377/hlthaff.w4.534
  • Ward, J. R., P. J. Clarkson, P. Buckle, J. Berman, R. Lim, and G. T. Jun. 2010. Prospective Hazard Analysis: Tailoring Prospective Methods to a Healthcare Context. Cambridge: Patient Safety Research Programme of the Department of Health.
  • Waterson, P., and K. Catchpole. 2016. “Human Factors in Healthcare: Welcome Progress, but Still Scratching the Surface.” BMJ Quality & Safety 25: 480–484. doi:10.1136/bmjqs-2015-005074.
  • WHSQ. 2007. Risk Management Code of Practice 2007 Supplement 2 – Risk Assessment. Queensland: Workplace Health and Safety Queensland Department of Justice and Attorney-General.
  • Wooldridge, A. R., P. Carayon, A. S. Hundt, and P. L. T. Hoonakker. 2017. “SEIPS-Based Process Modeling in Primary Care.” Applied Ergonomics 60: 240–254. doi:10.1016/j.apergo.2016.11.010.

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