Change Management

Case 1

1.          What is the difference between a negligence and a non-voluntary error?

The difference is:

A non-voluntary error is when you are trying to follow the rules but accidents or

mistakes happen anyway because of circumstances that are out of your control.  
For example: You are making a sandwich for a person with a gluten allergy, and you know that it's important to use different equipment, but someone forgot to wash it and the person gets sick anyway. This is a non-voluntary error because you wanted to do the right thing, but were prevented from doing so.
“Errors are not the disease. They are just symptoms of organizational disorder”

A negligence error is when you take a risk due to ignoring rules or guidelines and
the consequences. An example of this is: you are supposed to use different kitchen equipment for people with allergies, but you decide to ignore this because you don't think it's important enough and a person you serve food to gets sick because of you - it's a negligence error.

2.          How did FMEA help identify improvement actions that needed higher priority?

FMEA (Failure mode and effects analysis) is a team-based, systematic and proactive

approach for identifying the ways that a process or design can fail, why it might fail and

how it can be made safer.  It is used for reducing risk for users of a product or services,

in both the design and production stages. FMEA is a preventive tool and is often used in

hospitals, such as in this case. In this case the flowchart shows you how to take

advantage of an adverse event to improve safety in all processes.

The FMEA analysis starts with putting one activity in one flowchart and seeing whether

it has some sort of failure or not. When the failure modes of an activity have been

defined, the effect of each type of failure is evaluated. In this case they used the RPN

calculation to analyze the risks of all the activities, for all the 8 processes. They repeated

the RPN calculation for each activity by using all the 8 flowcharts, and the final step is to

compute the total risk, defined as:

RPN = S x O x D

S = the severity of the failure modes is ranked (scale 1-10)

O = the causes are identified and each cause is assigned a likelihood of occurrence (scale 1-10)

D = The likelihood of detection of the failure (scale 1-10)

The RPN scale goes from 1-1000.

The results of the analysis were that a total of 100 improvement actions were taken.

The RPN calculations were significantly lower after the implementation of the actions

and then the patient's safety were increased.

So how did the FMEA help identify improvement actions that needed higher priority?

The analysis ascertained what processes presented risks, the nature and severity of

those risks and their causes which also helped them to establish priorities for the right