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- Fyhr, AnnSofie, et al.
(författare)
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From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types
- 2015
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Ingår i: European Journal of Cancer Care. - : Hindawi Limited. - 1365-2354 .- 0961-5423.
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Tidskriftsartikel (refereegranskat)abstract
- A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs)in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason’s Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips,one-third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self-evaluation tool that would work as a complement to already incident reporting and event and risk analyses.
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| 3. |
- Ternov, Sven, et al.
(författare)
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A method, DEB analysis, for proactive risk analysis applied to air traffic control
- 2004
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535. ; 42:7, s. 657-673
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Complex production systems as, for instance, those used in health care, in off shore industry, in nuclear power industry or in aviation suffer now and then from severe system breakdowns. Lessons learnt from these often lead to changes in the "system". A more rational approach would be to identify these "system weaknesses" before accidents happen. A new proactive method, DEB analysis, for identifying hazards in a complex system was applied to an air traffic control unit in Malmoe, Sweden. The system weaknesses (i.e. latent system failures and insufficient safety barriers), which could cause these hazards, were identified. The effectiveness of the method was assessed by comparing these "prospective" identified system weaknesses with "retrospective" identified system weaknesses in a consecutive series of loss of separation cases (n = 15), investigated by the central aviation administration. Main findings: The system weaknesses in 14 out of the 15 cases were found with the proactive method. One sub-task was missed. Discussion: The method is an effective tool in disclosing system weaknesses that can give rise to hazards. The method should be modified with increased engagement of operators. It might be applied to other complex systems as well.
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| 4. |
- Ternov, Sven
(författare)
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Learning for safety in health care and air traffic control
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction Risk management in enterprises, organisations and companies has had a long and complicated history. During the eighties, and at least during the beginning of the nineties, the notion concerning risk management was that if an accident happened in an otherwise perfect system it was due to the human operator in some way being the cause of the error. The cause for the accidents was described in terms of “negligence”, “lack of competence” and such similar statements. Gradually, during the late nineties, the risk management paradigm shifted. James Reason, a psychologist, made a tremendous impact with his book Human error, published in 1990. He introduced the term latent failures (or latent conditions). These, he said, are “resident pathogens”, built into the system. They are latent since the system can live with these pathogens for months and even years, and perform adequately, until something happens, which hampers the “immune system of the system”. Reason states that the human operator goes to work everyday with the intention of doing a good job. The human operator has no wish “to screw up things”. When accidents happen, and operators make mistakes, it is therefore not a deliberate action. The causes should be sought in design flaws in the system. In this thesis we are dealing with high-risk systems, though not high-risk technologies. We are studying acute somatic health care, air traffic control, pharmacy and cancer treatment. We will explore different ways for an organisation to receive feedback from safety related occurrences, in order to improve safety. The aim with this thesis will be to explore methods for obtaining safety feedback in the above mentioned domains. Four different approaches will be attempted: • Retrospective learning from accidents (paper I) • Proactive learning using an external agent (paper II) • Operator centred learning (paper III) • User centred proactive learning (paper IV) Methods and material Methods In paper I we used MTO (Man-Technique-Organisation) analysis as described by the nuclear power operators in Sweden, with a certain adaptation for health care. Paper II was inspired on the work with paper I. During the numerous interviews with doctors and nurses a quite common reaction was: “Why did we not think of these risks before? It is so obvious!” Another concern was the limited value of retrospective investigations when it comes to improving safety. This started us on designing a method for proactive risk analysis. Several methods were already described for this, but they were mainly tuned to technical systems with more or less tight coupling, assuming a high degree of linearity (as for instance the Failure Mode and Effect Analysis, FMEA). We felt these methods did not fit the way in which our studied organisations functioned. The result was the DEB (Disturbance- Effect-Barrier) analysis used in paper II. The identified system weaknesses by using this method was compared to system weaknesses extracted from the analysis (done by headquarter analysts) of 15 loss of separation incidents at the unit. When working with this it became obvious that one category of incidents, i.e. the loss of separation incidents (AIRPROX) , was only the tip of the iceberg. Each day there were a number of near misses that did not result in loss of separation, and therefore not used for safety feedback. Talking to the controllers also revealed a hidden knowledge on questionable procedures that might constitute risks. Thus the idea was fairly simple: Why not let the controllers do the job of analysing safety occurrences? This led to the design of a method for operator-centred learning, i.e. paper III. The method included a brief to the controllers for 1½ days on system thinking. The starting point for paper IV was particularly tragic. I investigated a case where an eight-year-old girl with cancer was killed by mistake. She was administered the total dose of cytotoxic agents each day for three days, i.e. a 300% overdose. We used the DEB analysis again, for a proactive risk analysis of the process of treating patients with cytotoxic drugs, but this time using a formalised user group. Material The material for paper I was a consecutive series of eight reports to the National Board of Health and Welfare, from acute somatic health care. The material for paper II was a DEB analysis performed for the processes at the Malmoe air traffic control unit in Sweden. In paper III a trial was performed for half a year with extended reporting of learning occurrences. In this way an additional 45 occurrences were reported which otherwise would not have been documented and analysed. In paper IV the DEB analysis were performed at one ward unit at the department of oncology at the Lund University hospital, taking into consideration interface problems between the ward unit and the hospital pharmacy (which prepared the cytotoxic infusions). Results In paper I we could demonstrate that the notion of latent conditions was fruitful for analysing and learning from medical accidents. We identified a number of system weaknesses in seven out of eight cases, providing a good potential for improving safety. In paper II we identified a number of risks (latent conditions) in the air traffic control system. We compared the identified system weaknesses with 15 loss of separation cases, investigated by the regulator. We identified all system weaknesses from 14 out of 15 as loss of separation analyses. In paper III we could demonstrate that the operators indeed were able to analyse “learning occurrences”, and to identify preventive actions, one of these being training on the aircraft flight management system for controllers. Also, they could show that quite a few number of “unexpected flight behaviours” actually were actually partly caused by air traffic control actions. In paper IV we refined the DEB analysis by using a formalised reference group of staff from the very beginning.. The analysis disclosed a number of system weaknesses, which were presented for the staff. The disclosed risks were accepted as valid, and quite a few of our recommendations were implemented during the next couple of years Discussion We discuss our methods in relation to current research, particularly we discuss MTO analysis in relation to root cause analysis, and DEB analysis in relation to FMEA. We are critical to both. We find that both methods could benefit from using the notion of latent conditions, and even applying the concept and vocabulary from the ISO 9000 quality management standard when describing risks. We discuss the learning potential of retrospective vs. proactive analysis and are in favour of proactive methods. We introduce complexity theory and relate this to our results. Our conclusion is that the operator-centred approach (paper III) seems to be the most effective way of influencing a complex system in a desirable manner, concerning self-organising and emergent properties.
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| 5. |
- Ternov, Sven, et al.
(författare)
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Operator-centred local error management in air traffic control
- 2004
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535. ; 42:10, s. 907-920
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: A large number of air traffic control occurrences take place without resulting in loss of separation between aircraft. Unfortunately such occurrences are seldom reported and therefore not used for disclosing system weaknesses, Such as inappropriate methods and procedures. The ATCC (Air Traffic Control Centre) Malmoe made a trial with local reporting of "learning occurrences". The trial was ATCO-(Air Traffic Controller) centred. The study objectives were to evaluate if ATCOs would start to report after a defined training and marketing effort, if they could identify system weaknesses, if concrete actions for safety improvement would be taken as a result of the trial and to what extent expert support was necessary. Method and material: The trial period was eight months. The ATCO report would be made on a simple form, available on site. These reports would then be analysed in groups and the marketing and feedback efforts would be co-ordinated by the local flight safety group. Results: 43 reports were filed and analysed during the trial period. The initial motivational training and marketing was considered adequate. During the group discussions, the ATCOs identified system weaknesses within 40 of the reports. The resulting safety improvement actions included: the ATCC unit becoming more active in contacting the pilots and airline companies, the renaming of some waypoints (due to name similarities), the implementation of safer procedures when relieving ATCOs, the training of ATCOs in cockpit flight management systems, and the initiation of a research project primarily concerned with ATCO mental overload. Expert support was required in the beginning to help ATCOs focus on the system rather than on the individual.
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| 7. |
- Ternov, Sven, et al.
(författare)
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System weaknesses as contributing causes of accidents in health care
- 2005
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Ingår i: International Journal for Quality in Health Care. - : Oxford University Press (OUP). - 1464-3677 .- 1353-4505. ; 17:1, s. 5-13
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Tidskriftsartikel (refereegranskat)abstract
- Objectives. Accidents in health care, resulting in injury or death to the patient, are a matter of considerable concern. The aim of this study is to examine whether system weaknesses can contribute to these accidents, and if so, how. Design. Eight consecutive accidents reported to the Health Authority in Sweden were analysed using MTO (Man-Technique-Organization) analysis. Setting. Emergency care hospitals in Sweden. Results. All cases that involved the system supported the assumption that system weaknesses are a contributing factor to accidents. In this study two types of latent failure could be identified: process control latent failures and interactional latent failures. The time span from activation of process control latent failures to operator error was very short, and the study demonstrates the simple relationship between situational factors and operator errors. Interactional latent failures exert system influence in a more indistinct manner. Latent failures, as seen in this study, act not only by creating opportunities for operator errors but also by hindering error detection in the time window available. Safety barriers, which might have prevented the accidents, could be proposed in seven out of eight cases. Conclusion. System weaknesses seem to play an important role in accident evolution. Consequently, certain measures can be suggested in order to improve patient safety: (i) sufficient resources should be allocated for research and development at both medical schools and hospitals in order to establish competence and procedures for systematic analyses of processes; and (ii) authorities handling accident cases should have adequate competence in system analysis.
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