Figure 3-12

Mistake-Proofing the Design of Health Care Processes -

Figure 3.12. Create a detailed fault tree of the undesirable failure mode

Flow chart depicts mistake-proofing tools to create a detailed fault tree of the undesirable failure mode. The chart is divided into three sections: Enabling tools, Design tools, and Implementation tools. 'Enabling tools' lists five functions: Process mapping, Just culture, Event and near-miss reporting, Root cause analysis, and Visual systems (5S). 'Design tools' lists six functions, each leading to a 'Brainstorm' function, then to a filter which evaluates the number of possible solutions arising from the 'Brainstorm.' If the Brainstorm yields at least the desired number (n) of solutions, then the flow continues on to the function labeled 'Solution Set.' If 'n' is less than the desired number of solutions, tjem the flow continues to the next function. In sequence, the design tools functions are: Failure modes and effects analysis (FMEA); Fault tree analysis, which is highlighted for emphasis; Multiple fault tree analysis; TRIZ (the acronym for the 'theory of inventive problem solving' translated from Russian); Weaker cues; and Change focus or give up (last function, yielding zero solutions), which returns to 'Brainstorm'. In each case, 'Brainstorm' activity resulting in solutions greater than or equal to 'n' continue to the 'Solution set' function, which then continues to the final section, 'Implementation tools.' The 'Implementation tools' section is described: 'Lots of tools, but beyond the scope of this book.'

*The variable n equals the number of solutions you would like to generate before selecting the best one.
**TRIZ is the acronym for the "Theory of Inventive Problem Solving" translated from Russian.

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Current as of May 2007

Internet Citation: Figure 3-12: Mistake-Proofing the Design of Health Care Processes -. May 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/mistakeproof/mistakefig3-12.html