Adverse Event Investigation and Risk Assessment

Tommaso Bellandi,Michela Tanzini,Adriana Romani-Vidal,Paulo Sousa

doi:10.1007/978-3-030-59403-9_11

Abstract

AbstractThis chapter describes a comprehensive approach to adverse event investigation and risk assessment, as well as the characteristics of an integrated system for patient safety and clinical risk management. Drawing on evidence from other industries and healthcare organizations across the globe, the author’s report how such a system can be developed with the active involvement of policy-makers, healthcare managers, health professionals, and patients. Human factors and ergonomics provide the theoretical framework in which the guiding principles, methods, and tools are selected and applied to identify, analyze, and prevent risks related to unsafe care in any healthcare setting.

Highlights

Lower in those who work at a great distance from the frontline because the lack of direct contact with production processes and the context of operations pushes blunt end managers and designers to underestimate the dynamics of performance safety
The distance between the blunt end and the sharp end is in some cases accentuated by the fact that some political and organizational choices take place outside healthcare facilities and are based on risk and benefit assessments that are not always consistent with the mission of health facilities
Vincent and colleagues [25, 26] extended the Reason model to apply to the analysis of patient safety incidents, classifying the conditions of the clinical context that favor errors and the characteristics of the organizational system in a single frame of factors that influence clinical practices

Summary

11.1.1 Living with Uncertainty

Risk is an integral part of human activities, both in living and working environments. An individual performs a considerable number of actions, which, in most cases, are “inter-actions” with other people or tools or work environments. Interactions are more complex than elementary actions because the people, objects, or contexts with which we interact and offer opportunities for (affordance) and constraints on action [1–3]. Interactions have consequences that can change the status of objects or people.

Romani-Vidal Hospital Universitario Ramón y Cajal, Preventive Medicine, Madrid, Spain

11.1.2 Two Levels of Risk Management in Healthcare Systems

11.2 Patient Safety Management

11.3 Clinical Risk Management

11.4.1 The Dynamics of an Incident

11.4.2 A Practical Approach

11.5 Analysis of Systems and Processes Reliability

11.6 An Integrated Vision of Patient Safety