|
PREFACE |
6 |
|
ACKNOWLEDGEMENT |
7 |
|
1. THE ROLE OF FAULT TREES AND FMECAS IN
A HOSPITAL |
8 |
|
PURPOSE |
8 |
|
SOME DEFINITIONS (SEE
ALSO THE GLOSSARY) |
8 |
|
TWO TYPES OF
PREVENTABLE MEDICAL ERRORS |
8 |
|
THE HOSPITAL
ENVIRONMENT |
9 |
|
DIFFERENCE BETWEEN
JCAHO RECOMMENDED FMEAS AND IFTF |
10 |
|
DISCUSSION AND
RECOMMENDED IMPROVEMENTS |
11 |
|
A GENERIC FAILURE
EVENT SEQUENCE |
14 |
|
HOW A FAULT TREE /
FMECA HELPS TO MANAGE RISK |
16 |
|
FAULT TREE / FMECAS
HELP TO ORGANIZE KNOWLEDGE |
16 |
|
THE BENEFIT OF AN
INTEGRATED FAULT TREE / FMECA |
16 |
|
SOME LIMITATIONS OF A
FAULT TREE / FMECA |
17 |
|
ACCREDITATION VS.
QUALITY |
17 |
|
MANAGEABLE FAULT
TREES |
19 |
|
THE RELATIONSHIP
BETWEEN DESIGN AND ERROR REPORTING TOOLS |
19 |
|
APPENDIX – THE SPECTRUM OF PREVENTABLE
ERRORS |
23 |
|
2. GETTING STARTED |
24 |
|
PURPOSE |
24 |
|
OUTLINE OF THE
PROCESS |
24 |
|
SELECT A PROJECT |
24 |
|
CREATE A PROCESS
FLOWCHART |
24 |
|
BUILDING A SIMPLE
TREE |
27 |
|
THE PROJECT DATABASE |
27 |
|
ADDING SOME NODES |
27 |
|
OR GATES |
27 |
|
AND GATES |
28 |
|
BASIC GATES |
29 |
|
PRINTING THE FAULT
TREE |
29 |
|
AN ANALYSIS PREVIEW |
30 |
|
REVIEW |
31 |
|
ADDING FMECA
INFORMATION |
31 |
|
EVENT ATTRIBUTES |
31 |
|
FAILURE MODE AND
CAUSES |
31 |
|
FAILURE MODE EFFECTS |
32 |
|
FAULT DETECTION |
32 |
|
FAULT ISOLATION |
32 |
|
COMPONENT |
32 |
|
RECOVERY |
32 |
|
ACTION TAKEN |
32 |
|
COMMENTS |
33 |
|
REVIEW |
33 |
|
VIEWING FMECA
INFORMATION |
33 |
|
REPORT FEATURES |
34 |
|
REPORT FILTERS |
34 |
|
REPORT GROUPING
OPTIONS |
34 |
|
3. UNDERSTANDING FAULT TREES AND FMECAS |
36 |
|
INTRODUCTION |
36 |
|
THE SEQUENCE OF
POSSIBLE STEPS FOR A FAILURE MODE EVENT |
36 |
|
IMMEDIATE EFFECTS FOR
FAILURE MODE EVENTS |
37 |
|
THE BRAINSTORMING
MEETING FOR BUILDING THE TREE |
37 |
|
FACILITATING THE
MEETING |
37 |
|
FMEA AS A DESIGN
REVIEW |
38 |
|
BLOCK DIAGRAMS AS A
STARTING POINT FOR CONSTRUCTING A FAULT TREE |
38 |
|
CREATING BLOCK
DIAGRAMS AND PROCESS FLOWCHARTS |
39 |
|
WHEN A DETECTION OR
RECOVERY METHOD IS A PROCESS STEP |
41 |
|
USING PROCESS
FLOWCHARTS |
42 |
|
WHY THE PROCESS FLOW
CHART IS NEVER SUFFICIENT |
42 |
|
USING EXISTING
CHECKLISTS |
43 |
|
FAULT TREE RELATIVES |
43 |
|
MORE ABOUT SEVERITY |
44 |
|
MORE ABOUT
PROBABILITY |
45 |
|
FILLING IN THE FMECA
EVENTS |
46 |
|
INTRODUCTION |
46 |
|
THE FAILURE MODE AND
CAUSE FIELD |
46 |
|
THE FAILURE MODE
EFFECTS FIELD |
47 |
|
THE FAULT DETECTION
FIELD |
47 |
|
THE FAULT ISOLATION
FIELD |
48 |
|
THE COMPONENT FIELD |
48 |
|
THE RECOVERY FIELD |
49 |
|
UNDERSTANDING THE
ACTION TAKEN FIELD |
49 |
|
STATE OF KNOWLEDGE |
49 |
|
HIERARCHY OF ACTIONS
TAKEN |
49 |
|
CORRELATION BETWEEN
OF ACTION TAKEN AND STATE OF KNOWLEDGE |
50 |
|
REVIEW |
50 |
|
APPENDIX A - HOSPITAL LAB QSES |
51 |
|
APPENDIX B - HEALTHCARE QSES |
53 |
|
4. RISK ANALYSIS |
55 |
|
INTRODUCTION |
55 |
|
DANGERS IN SOME RISK
QUANTIFICATION SCHEMES – BEWARE THE RISK PRIORITY NUMBER (RPN) |
55 |
|
PARETO VIEWS IN THE
VIEW FMECA TAB |
56 |
|
PARTIAL PARETO |
56 |
|
FULL PARETO |
56 |
|
RISK MAP TAB |
56 |
|
CONTROLLING
PROBABILITY OF OCCURRENCE |
57 |
|
RISK CHART |
57 |
|
OVER-INTERPRETING THE
RISK MAP AND RISK CHART |
58 |
|
PROBABILITY CAN NEVER
BE ZERO |
59 |
|
EVENT MODELS |
59 |
|
DECISION ANALYSIS
MODELS |
60 |
|
5. MITIGATION STRATEGIES |
61 |
|
THE HIERARCHY OF
MITIGATION |
61 |
|
DESIGN CHANGES |
61 |
|
PREVENTING AN ERROR
SOURCE FROM OCCURRING |
61 |
|
REDUCING THE RATE OF
OCCURRENCE OF AN ERROR SOURCE |
62 |
|
TYPES OF DESIGN
CHANGES |
62 |
|
DETECTION – AUTOMATED
VS. MANUAL DETECTION |
62 |
|
EARLY DETECTION |
63 |
|
DETECTION VIEWED AS A
MEDICAL TEST |
63 |
|
RECOVERY CHANGES |
63 |
|
THE COST OF
MITIGATIONS |
64 |
|
THE RISK OF
MITIGATIONS CAUSING NEW PROBLEMS |
65 |
|
DETERMINING THE
QUALITY OF A RISK OF MITIGATION |
65 |
|
MITIGATIONS CAN
ALWAYS BE IMPROVED |
66 |
|
6. IFTF USER’S MANUAL |
67 |
|
PROGRAM DESCRIPTION |
67 |
|
HARDWARE REQUIREMENTS |
67 |
|
SOFTWARE REQUIREMENTS |
67 |
|
INSTALLATION |
67 |
|
FILES INSTALLED IN
THE IFTF DIRECTORY |
68 |
|
PROGRAM REMOVAL |
68 |
|
LICENSE |
68 |
|
FAULT TREE TAB |
70 |
|
ADDING A NODE |
70 |
|
EDITING A NODE |
71 |
|
DELETING NODE(S) |
71 |
|
CUT, COPY, AND PASTE |
71 |
|
EVENT NAME AND IDS |
71 |
|
PRINTING THE TREE |
72 |
|
EXITING THE PROGRAM |
72 |
|
ENTER FMECA TAB |
72 |
|
MAINTAINING THE
“COMPONENT LIST” |
73 |
|
MAINTAINING THE
“FAULT DETECTION LIST” |
73 |
|
VIEW FMECA TAB |
73 |
|
FILTERING DATA |
74 |
|
REPORT TYPES |
74 |
|
USING THE REPORT
TOOLBAR |
74 |
|
RISK MAP TAB |
75 |
|
RISK CHART TAB |
75 |
|
THE PROJECTS TAB |
75 |
|
CHANGING TO A NEW
PROJECT |
75 |
|
ADDING ONE PROJECT
(OR PART OF A PROJECT) INTO ANOTHER PROJECT |
75 |
|
CHANGING THE WORKING
DIRECTORY |
76 |
|
OPTIONS TAB |
76 |
|
NODE COLOR |
76 |
|
MAINTAIN RESPONSIBLE
LIST |
77 |
|
THE PROCESS FLOWCHART
TAB |
77 |
|
OPENING AN EXISTING
FLOWCHART |
77 |
|
SAVING A FLOWCHART |
77 |
|
CLEARING ALL
FLOWCHART OBJECTS |
77 |
|
CREATING A FLOWCHART |
77 |
|
WORKING WITH SHAPES |
77 |
|
WORKING WITH LINES |
78 |
|
COPYING OR DELETING
SHAPES AND LINES |
78 |
|
ADDING A TITLE |
78 |
|
GROUPING |
78 |
|
PRINTING THE
FLOWCHART |
78 |
|
ABOUT TAB |
79 |
|
USER PREFERENCES |
79 |
|
APPENDIX – DECIDING
ON PROGRAM FUNCTIONALITY |
80 |
|
QUANTIFYING
PROBABILITIES |
80 |
|
SECURITY, USERS, AND
AUDIT FUNCTIONS |
80 |
|
DEFINITIONS OF TERMS - GLOSSARY |
81 |
|
PROGRAM FAQS (FREQUENTLY ASKED QUESTIONS) |
82 |
|
ABOUT THE AUTHOR |
83 |