Accident Precursor Analysis and Management Reducing Technological Risk Through Diligence (2004) / Chapter Skim
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Section II Keynote Speakers2 The Opportunity of Precursors
Section II Keynote Speakers2 The Opportunity of Precursors
Pages 35-44
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Section II Keynote Speakers
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BAGIAN U.S. Department of Veterans Affairs National Center for Patient Safety One difficulty in identifying vulnerabilities in a system, sometimes called the precursor problem, is hindsight bias.
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RECOGNIZING OUTCOMES The aftermath of the Three Mile Islmd incident is inshuctive for understmding the perception of outcomes. Two divergent views of the incident emerged that were polar opposites md raised questions about how we define success.
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Is the pum, ose of the reporting system to look only at things that have caused an undesirable outcome, or is it also to scrutinize other things, such as close calls that almost resulted in undesirable outcomes but did not, either because of a last-minute "good catch" or because of plain good fortune? Close calls are extremely important areas of study because they are much more common than actual bad outcomes.
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MRI scanners have very strong magmets, and sandbags are sometimes inappropriately filled with ferromagmetic particles rather than sand. Had we relied on the so-called rate and incidence statistics culled from our reporting system, we would have concluded that this was not an important problem, because we had never received previous reports of such problems in MRI suites.
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A thorough analysis of underlying causes can provide insight into the problem and a basis for taking steps to correct or prevent the problem. For instance, we looked at a collection of RCAs dealing with cases in which incorrect surgical procedures were performed or incorrect sites were operated on.
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However, because we did not want the safety system to be used, or appear to be used, to hide events that all parties agree require disciplinary action, we decided to define events that were "blameworthy." We did not use legal terms, such as reckless or careless, that have been nnterp reted dffferendy in differeur jurisdictions. Instead, we defined a blameworthy act as an "intentionally unsafe act," that is, a criminal act, an act committed under the influence of drugs or alcohol, or a purposefully unsafe act.
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We realize that this approach could put leadership in a politically awkward position someday if a vulnerability for which we chose not to issue an alert resulted in a parent injury. But rather than taking a self-serving, nsk-averse position and sending out many more alerts, thus passing the responsibility and risk to the front line, VA leadership believes we can more effectively help patients by issuing alerts judiciously, even though the leadership is placed in greater personal/professional jeopardy.
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In the current system, which emphasizes close calls, 95 percent of reports are about close calls. Another important breakthrough was ensurmg that events that were reported resulted m action bemg taken.
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