Peter Pronovost’s very productive group examines a process by which previously unknown hazards that may be associated with the introduction of new health care services can be anticipated. The authors note that “One of the greatest challenges facing practitioners and risk managers is the identification of previously unknown hazards. These threats to patient safety often lie at the apex of available knowledge and are rarely – if ever – obvious. With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system.” They note that at present “a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated.” The authors emphasize the need to engage in this process before the new therapy or process is instituted. They describe the use of a multidisciplinary team of the key stake holders involved with a given project. The framework they propose is “composed of five process phases: 1) identify existing knowledge of hazards and defenses (literature review, communication with other institutions), 2) anticipate what can go wrong (brainstorm concerns, failure mode analysis), 3) simulate the process, 4) analyze hazards and defects, and 5) design the system to defend against such hazards (develop an operational protocol and check list to standardize the management of patient cases and to serve as a safety check for use prior to every case, monitor any patient safety events).” Details of these steps are provided and three clinical examples of this process are given in the article. Ref: Herzer KR: A practical framework for patient care teams to prospectively identify and mitigate clinical hazards. Jt Comm J Qual Patient Saf 2009;35:72-81
David S. Smith, M.D., Ph.D.