Teaching Proactive Risk Assessment to Clinicians and Administrators

Abstract

The Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS) is charged with developing and implementing the Veterans Health Administration’s (VHA) patient safety programs. This includes teaching human factors and risk assessment methods such as Healthcare Failure Mode and Effect Analysis (HFMEA™) to clinicians and administrators at over 150 facilities. The method for teaching proactive risk assessment described here uses a non-clinical example that encourages participant engagement and permits hands-on demonstration. In the present study, 32 clinicians, administrators, and other VHA staff completed the steps to conduct a proactive risk assessment on the topic of making s’mores over a campfire. An important finding was that the task analysis and review of all relevant risks and preventions was far more robust when the results from individual participants were aggregated. This suggests the value of a collaborative approach to conducting risk assessment within a health care system.