Different methods allow to investigate the contributing factors (human, material, organizational, structural ...), to analyze the preliminary causes essential to the search for adapted answers. Depending on a priori and a posteriori risks, the methods of analysis will be different.
The best known methods are the FMEA (Failure Mode Effects Analysis), the root-cause analysis, EXperience Return Committee (CREX in French), + Orion / ALARM. These analysis methods identify malfunctions and mitigate these risks through the implementation of corrective solutions.
Beyond these methods, relying on digital solutions for risk analysis is an issue in organizations. They have the advantage of structuring the search of contributing and latent factors, of the root causes of the occurrence.
This multidisciplinary approach allows, apart from any guilty approach to understand the chain of circumstances, situations and acts that have led to the expression of a risk which is the triggering factor of these analyzes.
Following a septic shock, a patient was taken in charge in surgery. This event necessitated a thorough analysis of the occurrence conditions. Whatever the method used, each dimension of the management is chronologically analyzed, associating all the factors that may have led to this infection.
Among these facts: organization, practices, team, logistics, but also the patient. Originally from Central Europe, the patient did not speak French. The barrier of the language did not facilitate exchange and understanding. Therefore the follow-up of the recommendations led her to take a shower without occlusive dressing (following a change of dressing set). This action resulted in a wound infection.
In this example, the nurse by noticing the wound degradation affecting the general condition of the patient has, of course, started by alerting the doctor of the department and then disclosing the adverse event. This reporting was automatically transmitted, as soon as validation, to the quality department and the referent in charge of the infectious risks prevention.
The "Risk Management" unit of the health facility characterizing the event as serious, decided to set up a root cause analysis using the ALARM method, the method in force at the institution.
Through the adverse event reporting tool, the quality referrer triggered a meeting by inviting the engaged professionals or functions to participate.
Digitizing adverse event reporting process and workflows generated specific alerts. After a chronological search of the facts, all the factors were analyzed.
In order to avoid a replication of this adverse event in the future, improvement measures have been recommended:
To be able to link all of this information (event, action, risk, process of adverse event treatment) and whatever the request, be able to consolidate all these elements to follow the answers. These are the advantages of a reactivity that only digitization allows to optimize.
Following the ALARM analysis, processes of patients care, control and maintenance were redefined. Personnel awareness of the risk factors related to care of the patient and those around him was also made.
It is the diversity of these factors, characteristic of the risks that we must map. Digital technology allows to classify before allowing the control by the different actors.
For further :
> Digitize your risk analysis methods with BlueKanGo Health
> Download the guide "The new orientation of Quality and Risk Management"