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PREFACE
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6
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ACKNOWLEDGEMENT
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7
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1. THE ROLE OF FAULT TREES AND
FMECAS IN A HOSPITAL
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8
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PURPOSE
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8
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SOME
DEFINITIONS (SEE ALSO THE GLOSSARY)
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8
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TWO TYPES OF
PREVENTABLE MEDICAL ERRORS
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8
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THE HOSPITAL
ENVIRONMENT
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9
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DIFFERENCE
BETWEEN JCAHO RECOMMENDED FMEAS AND IFTF
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10
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DISCUSSION
AND RECOMMENDED IMPROVEMENTS
|
11
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|
A GENERIC
FAILURE EVENT SEQUENCE
|
14
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HOW A FAULT
TREE / FMECA HELPS TO MANAGE RISK
|
16
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FAULT TREE /
FMECAS HELP TO ORGANIZE KNOWLEDGE
|
16
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|
THE BENEFIT
OF AN INTEGRATED FAULT TREE / FMECA
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16
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SOME
LIMITATIONS OF A FAULT TREE / FMECA
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17
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ACCREDITATION
VS. QUALITY
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17
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MANAGEABLE
FAULT TREES
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19
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THE
RELATIONSHIP BETWEEN DESIGN AND ERROR REPORTING TOOLS
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19
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|
APPENDIX – THE SPECTRUM OF
PREVENTABLE ERRORS
|
23
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|
2. GETTING STARTED
|
24
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PURPOSE
|
24
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|
OUTLINE OF
THE PROCESS
|
24
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|
SELECT A
PROJECT
|
24
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|
CREATE A
PROCESS FLOWCHART
|
24
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|
BUILDING A
SIMPLE TREE
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27
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|
THE PROJECT
DATABASE
|
27
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|
ADDING SOME
NODES
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27
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|
OR GATES
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27
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AND GATES
|
28
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BASIC GATES
|
29
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|
PRINTING THE
FAULT TREE
|
29
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|
AN ANALYSIS
PREVIEW
|
30
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|
REVIEW
|
31
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|
ADDING FMECA
INFORMATION
|
31
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|
EVENT
ATTRIBUTES
|
31
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|
FAILURE MODE
AND CAUSES
|
31
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|
FAILURE MODE
EFFECTS
|
32
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|
FAULT
DETECTION
|
32
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|
FAULT
ISOLATION
|
32
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COMPONENT
|
32
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RECOVERY
|
32
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ACTION TAKEN
|
32
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COMMENTS
|
33
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REVIEW
|
33
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|
VIEWING FMECA
INFORMATION
|
33
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|
REPORT
FEATURES
|
34
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|
REPORT
FILTERS
|
34
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|
REPORT
GROUPING OPTIONS
|
34
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|
3. UNDERSTANDING FAULT TREES AND
FMECAS
|
36
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|
INTRODUCTION
|
36
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|
THE SEQUENCE
OF POSSIBLE STEPS FOR A FAILURE MODE EVENT
|
36
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|
IMMEDIATE
EFFECTS FOR FAILURE MODE EVENTS
|
37
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|
THE
BRAINSTORMING MEETING FOR BUILDING THE TREE
|
37
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FACILITATING
THE MEETING
|
37
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|
FMEA AS A
DESIGN REVIEW
|
38
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BLOCK
DIAGRAMS AS A STARTING POINT FOR CONSTRUCTING A FAULT TREE
|
38
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CREATING
BLOCK DIAGRAMS AND PROCESS FLOWCHARTS
|
39
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|
WHEN A
DETECTION OR RECOVERY METHOD IS A PROCESS STEP
|
41
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USING PROCESS
FLOWCHARTS
|
42
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|
WHY THE
PROCESS FLOW CHART IS NEVER SUFFICIENT
|
42
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|
USING
EXISTING CHECKLISTS
|
43
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|
FAULT TREE
RELATIVES
|
43
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|
MORE ABOUT
SEVERITY
|
44
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|
MORE ABOUT
PROBABILITY
|
45
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|
FILLING IN
THE FMECA EVENTS
|
46
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|
INTRODUCTION
|
46
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THE FAILURE
MODE AND CAUSE FIELD
|
46
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|
THE FAILURE
MODE EFFECTS FIELD
|
47
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|
THE FAULT
DETECTION FIELD
|
47
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|
THE FAULT
ISOLATION FIELD
|
48
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|
THE COMPONENT
FIELD
|
48
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THE RECOVERY
FIELD
|
49
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|
UNDERSTANDING
THE ACTION TAKEN FIELD
|
49
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|
STATE OF
KNOWLEDGE
|
49
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|
HIERARCHY OF
ACTIONS TAKEN
|
49
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CORRELATION
BETWEEN OF ACTION TAKEN AND STATE OF KNOWLEDGE
|
50
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|
REVIEW
|
50
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|
APPENDIX A - HOSPITAL LAB QSES
|
51
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APPENDIX B - HEALTHCARE QSES
|
53
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4. RISK ANALYSIS
|
55
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INTRODUCTION
|
55
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DANGERS IN
SOME RISK QUANTIFICATION SCHEMES – BEWARE THE RISK PRIORITY
NUMBER (RPN)
|
55
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|
PARETO VIEWS
IN THE VIEW FMECA TAB
|
56
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|
PARTIAL
PARETO
|
56
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|
FULL PARETO
|
56
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RISK MAP TAB
|
56
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CONTROLLING
PROBABILITY OF OCCURRENCE
|
57
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|
RISK CHART
|
57
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|
OVER-INTERPRETING THE RISK MAP AND RISK CHART
|
58
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|
PROBABILITY
CAN NEVER BE ZERO
|
59
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|
EVENT MODELS
|
59
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|
DECISION
ANALYSIS MODELS
|
60
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|
5. MITIGATION STRATEGIES
|
61
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THE HIERARCHY
OF MITIGATION
|
61
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|
DESIGN
CHANGES
|
61
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|
PREVENTING AN
ERROR SOURCE FROM OCCURRING
|
61
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REDUCING THE
RATE OF OCCURRENCE OF AN ERROR SOURCE
|
62
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|
TYPES OF
DESIGN CHANGES
|
62
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|
DETECTION –
AUTOMATED VS. MANUAL DETECTION
|
62
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|
EARLY
DETECTION
|
63
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|
DETECTION
VIEWED AS A MEDICAL TEST
|
63
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|
RECOVERY
CHANGES
|
63
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|
THE COST OF
MITIGATIONS
|
64
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|
THE RISK OF
MITIGATIONS CAUSING NEW PROBLEMS
|
65
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DETERMINING
THE QUALITY OF A RISK OF MITIGATION
|
65
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|
MITIGATIONS
CAN ALWAYS BE IMPROVED
|
66
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6. IFTF USER’S MANUAL
|
67
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|
PROGRAM
DESCRIPTION
|
67
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|
HARDWARE
REQUIREMENTS
|
67
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|
SOFTWARE
REQUIREMENTS
|
67
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|
INSTALLATION
|
67
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|
FILES
INSTALLED IN THE IFTF DIRECTORY
|
68
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|
PROGRAM
REMOVAL
|
68
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|
LICENSE
|
68
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|
FAULT TREE
TAB
|
70
|
|
ADDING A NODE
|
70
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|
EDITING A
NODE
|
71
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|
DELETING
NODE(S)
|
71
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|
CUT, COPY,
AND PASTE
|
71
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|
EVENT NAME
AND IDS
|
71
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|
PRINTING THE
TREE
|
72
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|
EXITING THE
PROGRAM
|
72
|
|
ENTER FMECA
TAB
|
72
|
|
MAINTAINING
THE “COMPONENT LIST”
|
73
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|
MAINTAINING
THE “FAULT DETECTION LIST”
|
73
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|
VIEW FMECA
TAB
|
73
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|
FILTERING
DATA
|
74
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|
REPORT TYPES
|
74
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|
USING THE
REPORT TOOLBAR
|
74
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|
RISK MAP
TAB
|
75
|
|
RISK CHART
TAB
|
75
|
|
THE PROJECTS
TAB
|
75
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|
CHANGING TO A
NEW PROJECT
|
75
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|
ADDING ONE
PROJECT (OR PART OF A PROJECT) INTO ANOTHER PROJECT
|
75
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|
CHANGING THE
WORKING DIRECTORY
|
76
|
|
OPTIONS TAB
|
76
|
|
NODE COLOR
|
76
|
|
MAINTAIN
RESPONSIBLE LIST
|
77
|
|
THE PROCESS
FLOWCHART TAB
|
77
|
|
OPENING AN
EXISTING FLOWCHART
|
77
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|
SAVING A
FLOWCHART
|
77
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|
CLEARING ALL
FLOWCHART OBJECTS
|
77
|
|
CREATING A
FLOWCHART
|
77
|
|
WORKING WITH
SHAPES
|
77
|
|
WORKING WITH
LINES
|
78
|
|
COPYING OR
DELETING SHAPES AND LINES
|
78
|
|
ADDING A
TITLE
|
78
|
|
GROUPING
|
78
|
|
PRINTING THE
FLOWCHART
|
78
|
|
ABOUT TAB
|
79
|
|
USER
PREFERENCES
|
79
|
|
APPENDIX –
DECIDING ON PROGRAM FUNCTIONALITY
|
80
|
|
QUANTIFYING
PROBABILITIES
|
80
|
|
SECURITY,
USERS, AND AUDIT FUNCTIONS
|
80
|
|
DEFINITIONS OF TERMS - GLOSSARY
|
81
|
|
PROGRAM FAQS (FREQUENTLY ASKED
QUESTIONS)
|
82
|
|
ABOUT THE AUTHOR
|
83
|