What an interesting process failure analysis is? I have been working with my colleague Linda Williams at the National Center for Patient Safety on analyzing opportunities for failure in the knowledge transfer process. BTW, it’s an honor to work with Linda as her organization has embraced the notion of Failure Mode and Effects Analysis (FMEA) and applied it quite successfully within the health care domain at the clinical end -- I am sure much will be learned by looking at Knowledge Transfer through this lens.
In our preliminary work, we are currently focusing on the process clinicians use to fill a gap in their knowledge base and have noted such elements as consulting colleagues (see my posting below from October 21], accessing decision support systems and use of Google as parts of the process where failure can occur.
Linda and I will be presenting on this topic at the upcoming Medical Library Association symposium on patient safety to be held in May of 2006 and welcome any comments from the field as we shape the model we’ll be sharing with our colleagues there. I'll post more information on that session as it becomes available.
Maximize benefits of IV workflow management systems by addressing workarounds and errors. - ISMP Medication Safety Alert! Acute Care Edition. September 7, 2017;22:1-4.
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