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At the end of the chapter, the reader will be able to:


  1. Recognize problems associated with identifying quality issues and solutions.

  2. Select an appropriate topic for analysis.

  3. Support the use of root cause analysis.

  4. Support the use of Healthcare Failure Modes and Effects Analysis (HFMEASM).


In this chapter, we will talk about how to identify the causes of quality problems.

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Detectable hazard: A very evident potential risk that will be promptly discovered before it hampers the completion of an activity (e.g., an IV bag that is leaking).
Effective control measure: A barrier that eliminates or substantially reduces the likelihood of a hazardous event occurring (e.g., the pharmaceutical form of some medications prevents its use via the wrong administration route such as I tubing that only connects for IV catheter, not nasal cannula).
Failure mode: Different ways that a process or subprocess can fail to provide the anticipated result.
Failure mode cause: Different reasons as to why a process or subprocess would fail to provide the anticipated result.
Hazard analysis: Identification and evaluation of potential hazards that are likely to produce harm in a specific process if not controlled.
Healthcare Failure Modes and Effects Analysis (HFMEASM): A systematic approach to identify and prevent product and process problems before they occur.
Single point weakness: A step in the process so critical that its failure would result in system failure or an adverse event (e.g., the prescriber order is processed for the wrong patient; this would result in the preparation, delivery, and administration of the wrong medications).

There are many problems associated with identifying quality issues and solutions; many of these are called heuristics and judgmental biases. In many cases, decision makers rely on a limited number of heuristic principles (or simple decision rules) to reduce cognitively complex decision-making tasks to simpler judgmental operations.1,2 Although many heuristics exist, only those more commonly mentioned in the literature will be described. Some common heuristics are included in Table 7-1.

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Table 7-1. Problems Associated with Assigning Causes and Choosing Solutions

Often, humans prefer to use heuristics rather than utilizing more complex cognitive processes such as decision making.2 Heuristics can be useful or can lead to error, depending on the situation (Tversky and Khaneman, 1982b).1,2,7 It is important to recognize these common heuristics as potential sources of error so that decision-making techniques can be implemented to reduce the impact of these cognitive biases.3


For example, when using the availability heuristic, the ...

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