Learn to use a ‘What-If’ patient safety analysis
Learn to use a What-If’ patient safety analysis
Assemble an experienced review team
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
"What-If" analysis is a structured brainstorming method of determining what things can go wrong and judging the likelihood and consequences of those situations occurring. The answers to those questions form the basis for making judgments regarding the acceptability of those risks and determining a recommended course of action for those risks judged to be unacceptable. An experienced review team can effectively identify major patient safety concerns in a process or system.
During a What-If analysis, the team assesses what can go wrong based on past experiences and knowledge of similar situations. At each step in the process, What-If questions are asked and answers generated. To minimize the chance that potential problems are overlooked, the team doesn’t make any improvement recommendations until all of the potential patient safety hazards are identified. The review team then makes judgments regarding the likelihood and severity of the "What-If" answers. If the risk indicated by those judgments is unacceptable, then a process improvement recommendation is made by the team.
The first steps in performing an effective What-If analysis include picking the boundaries of the review, involving the right individuals, and assembling the right information. The boundaries of the review may be a single task, a collection of related tasks, or a complete process. The narrower the review focus, the greater the likelihood of explicit improvement recommendations. When the review boundaries are too wide, the team’s findings and recommendations tend to become more general in nature.
Assembling an experienced, knowledgeable review team probably is the single most important element in conducting a successful What-If analysis. Including individuals experienced in the day-to-day tasks is essential. Their knowledge of performance standards, past and potential errors, as well as task difficulties bring a practical reality to the review. Consider also including recently hired staff members on the review team to gain their perspective.
Once the team is assembled, the next step is conducting the analysis. An experienced patient safety review facilitator should be chosen to lead the group through a series of "What-If" questions. In addition, the team should be provided with clerical support to take notes of the review.
With input from the team, a list of What-If questions is formulated. The questions could address situations such as:
- Failure to follow procedures or procedures followed incorrectly
- Procedures incorrect or latest procedures not used
- Staff inattentive or not trained
- Equipment failures
- Workplace influences such as lighting, noise, staff fatigue
- Combination of events such as multiple task failures
Team members who are knowledgeable of past process failures and likely sources of errors should be able to quickly develop these questions. For example, consider the task of selecting medications in a computerized order-entry system. Some typical What-If questions that could be generated by the team are listed below:
- What if the wrong medication is chosen from the pick list?
- What if the lighting makes it difficult to see the computer screen?
- What if the wrong patient name is entered into the computer?
- What if the wrong strength, unit, or dosage form is chosen from the pick list?
- What if the physician’s written order is illegible?
As the What-If questions are being generated, the facilitator should ensure that each member of the team has an opportunity to identify potential errors or failures. Don’t stop during the generation of the question list to answer the questions; otherwise, the team may not spend enough time on question generation. The facilitator should assess if the team has really looked at all of the possibilities before going to the next step of answering the questions. It can often be helpful to break up the analysis into smaller pieces of the process if it appears that people are too quickly moving ahead to answering the questions.
After the review team has exhausted the most credible What-If scenarios, the facilitator then has the team answer the question, what would be the result if that situation actually occurred? For example, what would happen if the wrong patient name is entered into the computer? If done correctly, reviewing the possible process failures and human errors can point out the opportunities for patient safety improvements as well as efficiency improvements. As each What-If scenario is discussed, the team also judges the likelihood and severity of the situation it is describing. The discussion of the situation leads naturally to recommendations for improvement.
The team continues the analysis question by question until the entire process has been analyzed. At this point, the team should step back and review the big picture to determine if it has inadvertently missed anything.
Once the hard work of conducting the analysis has been completed, a report of the project should be prepared for the patient safety committee or other management group. The leader of the review team can create a cover memo that details the scope of the review as well as the major findings, recommendations, names of people who have been assigned responsibility to take actions, time frame for completion, and measures of success. This cover memo can be attached to the completed What-If Analysis Form. (See box, below.) A periodic report should be generated to summarize the present status of each of the recommendations and measurement results.
The What-If analysis technique is simple to use and can be applied effectively to a variety of patient care and business processes. No specialized tools or techniques are needed. Individuals with little hazard analysis training can participate in a full and meaningful way. The results of the analysis are available immediately and usually can be applied quickly. On the other hand, the technique does rely heavily on the experience and intuition of the review team. It is somewhat more subjective than other methods, such as failure mode and effect analysis (FMEA), which require a more formal and systematized approach. If all of the appropriate What-If questions are not asked, this technique can be incomplete and miss some hazard potentials. It may be better to do a more rigorous FMEA on high-risk processes or those with known patient safety problems.
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Example of Completed What-If Analysis Form
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| Division: Nursing Date: 9/2004 |
Description of Task: Nurse entry of physician medication orders into computer |
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| What If? | Answer | Likelihood | Consequences | Recommendations |
| What if the wrong medication is chosen from the pick list? |
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Possible | Serious | Change pick list to include ’Tall Man” letters and color coding to assist in differentiating between medication |
| What if the lighting makes it difficult to see computer screen? |
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Unlikely | Minor | No action recommended at this time |
| What if the wrong patient name is entered in computer? |
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Possible | Serious | Reinforce pharmacy checks to catch these types of errors prior to dispensing medication |
| What if the wrong strength, unit, or dosage form is chosen from the pick list? |
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Quite Possible | Very serious | Nurse to confirm medication strength, unit, and/or dosage with written order prior to administration of first dose |
| What if physician’s written order is illegible? |
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Quite Possible | Minor | No action recommended at this time |
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