Proactive risk assessment in the ED: Building the 'safety case'

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DESCRIPTION (provided by the applicant): There are 3 broad, long-term objectives for this proposal: 1) to extend the techniques of proactive risk assessment (PRA) used in high hazard industries into a health care setting, 2) to adapt the technique of creating a 'safety case' for a system change (also common in high hazard industries) to a health care setting; and 3) to examine the concepts of resilience engineering for use in supplementing a PRA. The case of replacing manual status boards in emergency departments (EDs) with computerized tracking systems will be used as a 'test bed' for the project. The specific aims of the project therefore are: 1. To identify the specific ways in which the status board supports patient safety, or poses risks to patients. 2. To conduct a PRA for replacing manual with computer-based status boards in EDs. Because risks may vary under different operating conditions, this will be a phased risk assessement. 3. To produce a 'safety case' argument for that change based on the results of the PRA exercise. 4. To produce a generalizable methodology for conducting such assessments in health care in the future. Methods. Prior work on the cognitive properties of the status board will be used to identify functionality with direct implications for patient safety. Process mapping techniques, direct observations of work and semistructured interview with ED staff will be used to gather data on system operations. These will be analyzed in a sociotechnical PRA framework. The results will be independently reviewed panel to increase generality. The project has substantial relevance to public health. Health care organizations commonly make major changes in processes, people and technology (eg, opening specialized trauma or stroke centers, or installing computerized provider order entry systems) with little or no prospective examination of the hazards that may be induced by such changes. If PRA methods can be successfully transported to health care and used to build safety case arguments prior to such changes (and to maintain those arguments over the life of the system), unintended consequences for patients and staff may be reduced, and beneficial change facilitated.