Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly.
failure modes and effects analysis (FMEA)
human error
patient safety
root cause analysis
Journal
BMJ open quality
ISSN: 2399-6641
Titre abrégé: BMJ Open Qual
Pays: England
ID NLM: 101710381
Informations de publication
Date de publication:
Sep 2020
Sep 2020
Historique:
received:
29
02
2020
revised:
08
07
2020
accepted:
12
08
2020
entrez:
5
9
2020
pubmed:
5
9
2020
medline:
17
9
2020
Statut:
ppublish
Résumé
To analyse a medical accident, much time and experience are needed. However, people without experience in analysis have difficulty understanding its conditions and methods, and as a result it takes longer to establish countermeasures. It must be noted that understanding conditions by simply aligning occurrences in the accident in a chronological order is difficult. A workflow chart that considers time was proposed so that individuals without adequate experience in analysis could easily carry out root cause analysis. In the 'workflow chart (WFC)', the time sequence was described horizontally. On the vertical axis, the business manual, the occurrence of the accident, and the time of the occurrence are displayed. In the bottom column of patient event, information regarding damage to patients was written in accordance with time axis. Regarding the degree of damage, the time of error until the accident was identified was connected using a straight line (when the patient was not affected, a dotted line was used) in order to show the overall picture of the accident. According to the time flow chart, hints to identify potential risks were proposed. Focus was placed not only on the error event, but also on keywords such as manual inadequacy, time gap, degree of error and so on to easily lead to the question 'why?' To visualise this, I proposed an operation flow chart. By using time-WFC, even beginners can easily develop accident countermeasure strategies. Using a WFC that considers time, time of error and the occurrence of accident could be visualised. As a result, even individuals without experience in analysis could easily perform an analysis.
Sections du résumé
BACKGROUND
BACKGROUND
To analyse a medical accident, much time and experience are needed. However, people without experience in analysis have difficulty understanding its conditions and methods, and as a result it takes longer to establish countermeasures. It must be noted that understanding conditions by simply aligning occurrences in the accident in a chronological order is difficult.
PURPOSE
OBJECTIVE
A workflow chart that considers time was proposed so that individuals without adequate experience in analysis could easily carry out root cause analysis.
METHODS
METHODS
In the 'workflow chart (WFC)', the time sequence was described horizontally. On the vertical axis, the business manual, the occurrence of the accident, and the time of the occurrence are displayed. In the bottom column of patient event, information regarding damage to patients was written in accordance with time axis. Regarding the degree of damage, the time of error until the accident was identified was connected using a straight line (when the patient was not affected, a dotted line was used) in order to show the overall picture of the accident.
RESULTS
RESULTS
According to the time flow chart, hints to identify potential risks were proposed. Focus was placed not only on the error event, but also on keywords such as manual inadequacy, time gap, degree of error and so on to easily lead to the question 'why?' To visualise this, I proposed an operation flow chart. By using time-WFC, even beginners can easily develop accident countermeasure strategies.
CONCLUSION
CONCLUSIONS
Using a WFC that considers time, time of error and the occurrence of accident could be visualised. As a result, even individuals without experience in analysis could easily perform an analysis.
Identifiants
pubmed: 32883676
pii: bmjoq-2020-000960
doi: 10.1136/bmjoq-2020-000960
pmc: PMC7474900
pii:
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Déclaration de conflit d'intérêts
Competing interests: None declared.
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