A practical framework for patient care teams to prospectively identify and mitigate clinical hazards

Kurt R. Herzer, Jose Manuel Rodriguez-Paz, Peter A. Doyle, Paul Warren Flint, David J. Feller-Kopman, Joseph Herman, Robert Bristow, Renee Cover, Peter J Pronovost, Lynette J. Mark

Research output: Contribution to journalArticlepeer-review

25 Scopus citations


Background: One of the greatest challenges facing both practitioners and risk managers is the identification of previously unknown clinical hazards and defects. With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system. The main goal of risk analysis is to make these hazards visible by proactively searching and probing the system. Yet, a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated. Patient care teams can use the proposed framework when introducing new therapies. A Practical Framework: The framework includes a background investigation and literature search; an in situ simulation (in the actual clinical setting used for patients); a Failure Mode and Effects Analysis to determine the severity, probability, and risk of the potential hazards; and a multi-disciplinary protocol and safety checklist to standardize practice and ensure provider accountability. Case Examples: Application of this framework to three operative scenarios - intraoperative radiation therapy (IORT), hyperthermic intraperitoneal chemotherapy (HIPEC), and an interventional pulmonology program - demonstrates its flexibility. Its use prospectively identified and mitigated 20 IORT, 5 HIPEC, and 18 interventional pulmonology hazards/defects. Subsequent patient cases were largely uneventful. All cases and patient safety reporting systems are monitored to identify any new defects in an effort to continuously improve patient care. Conclusion: The use of a comprehensive framework to identify and mitigate hazards in an on-site simulated environment promotes safer care for target patient populations; results in familiarity with procedures, amelioration of staff concerns, and standardization of practice; and facilitates teamwork and communication.

Original languageEnglish (US)
Pages (from-to)72-81
Number of pages10
JournalJoint Commission Journal on Quality and Patient Safety
Issue number2
StatePublished - Feb 2009

ASJC Scopus subject areas

  • Leadership and Management


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