Background
Aims
Method
Design
Setting
Participants
Procedure
Results
Number of risks identified by each prospective method
Task analysis section | Total number of risks identified | Number of most important risks |
---|---|---|
1.1 Obtain patient list for community-based clinic | 16 | 1 (‘Failure or delay in referral’) |
1.2 Invite patient | 7 | 0 |
1.3 Schedule appointment | 5 | 1 (‘Incomplete checklist information - judgement call, treatment delayed, patient does not get treatment’) |
2.1 Obtain recent medical history | 13 | 0 |
2.2 Obtain international normalised ratio (INR) | 5 | 1 (‘Incorrect recording of INR – cannot change INR once entered’) |
2.3 Determine dose and time until next appointment | 10 | 0 |
2.4 Conclude appointment | 5 | 0 |
TOTAL
|
61
|
3
|
Task analysis section | Total number of risks | Number of risks with proceed decision | Number of risks with proceed decision and a red risk rating |
---|---|---|---|
1.1 Obtain patient list for community-based clinic | 8 | 3 | 1 |
1.2 Invite patient | 12 | 4 | 1 |
1.3 Schedule appointment | 13 | 9 | 2 |
2.1 Obtain recent medical history | 14 | 7 | 1 |
2.2 Obtain international normalised ratio | 5 | 2 | 0 |
2.3 Determine dose and time until next appointment | 8 | 7 | 4 |
2.4 Conclude appointment | 12 | 10 | 3 |
TOTAL
|
72
|
42
|
12
|
Types of risks identified by each prospective method
Section | Risks identified by SWIFT | Risks identified by HFMEA | ||
---|---|---|---|---|
1.1 Obtain patient list for community-based clinic | 16 risks identified | 3 also identified by HFMEA | 8 risks identified | 2 also identified by SWIFT |
1 partially identified by HFMEA | 1 partially identified by SWIFT | |||
12 not identified by HFMEA | 5 not identified by SWIFT | |||
1.2 Invite patient | 7 risks identified | 1 also identified by HFMEA | 12 risks identified | 2 also identified by SWIFT |
2 partially identified by HFMEA | 3 partially identified by SWIFT | |||
4 not identified by HFMEA | 7 not identified by SWIFT | |||
1.3 Schedule appointment | 5 risks identified | 0 also identified by HFMEA | 13 risks identified | 0 also identified by SWIFT |
1 partially identified by HFMEA | 1 partially identified by SWIFT | |||
4 not identified by HFMEA | 12 not identified by SWIFT | |||
2.1 Obtain recent medical history | 13 risks identified | 6 also identified by HFMEA | 14 risks identified | 5 also identified by SWIFT |
2 partially identified by HFMEA | 4 partially identified by SWIFT | |||
5 not identified by HFMEA | 5 not identified by SWIFT | |||
2.2 Obtain international normalised ratio | 5 risks identified | 4 also identified by HFMEA | 5 risks identified | 4 also identified by SWIFT |
1 partially identified by HFMEA | 0 partially identified by SWIFT | |||
0 not identified by HFMEA | 1 not identified by SWIFT | |||
2.3 Determine dose and time until next appointment | 10 risks identified | 1 also identified by HFMEA | 8 risks identified | 1 also identified by SWIFT |
4 partially identified by HFMEA | 4 partially identified by SWIFT | |||
5 not identified by HFMEA | 3 not identified by SWIFT | |||
2.4 Conclude appointment | 5 risks identified | 2 also identified by HFMEA | 12 risks identified | 2 also identified by SWIFT |
0 partially identified by HFMEA | 1 partially identified by SWIFT | |||
3 not identified by HFMEA | 9 not identified by SWIFT | |||
TOTAL
|
61 risks identified
|
17 also identified by HFMEA
|
72 risks identified
|
16 also identified by SWIFT
|
11 partially identified by HFMEA
|
14 partially identified by SWIFT
| |||
33 not identified by HFMEA
|
42 not identified by SWIFT
|
Comparison of prospective methods with prior safety work
Participants’ feedback
Questions | HFMEA | SWIFT |
---|---|---|
In your opinion did the workshop identify the most serious hazards in the care of patients? | Yes 4 | Yes 5 |
No 1 | No 0 | |
Did the workshop identify realistic hazards? That is, things that realistically might go wrong? | Yes 5 | Yes 5 |
No 0 | No 0 | |
Did the workshop identify new hazards that you were not aware of before? | Yes 4 | Yes 5 |
No 1 | No 0 | |
Has the workshop changed your understanding of the risks in your work? | Yes 4 | Yes 1 |
No 1 | No 4 | |
Was the process easy to understand? | Yes 5 | Yes 5 |
No 0 | No 0 | |
Did everyone contribute to the discussion? | Yes 5 | Yes 5 |
No 0 | No 0 | |
What were the main benefits of the workshop? (free text; multiple answers possible) | • Identified hazards (4) | • Discussion (2) |
• Identified actions (1) | • Increased understanding of the clinic (1) | |
• Increased awareness of risks (1) | • Forum for reflection (1) | |
• Increased understanding of the clinic (1) | ||
• Systematic (1) | ||
What were the main limitations of the workshop? (free text; multiple answers possible) | • Lack of time (5) | • Lack of time (4) |
• Session was long (1) | ||
• Dry (1) |