Fault tree analysis, a technique that originated in private industry to test systems’ reliability and safety, offers promise in identifying factors that lead to medical diagnostic errors, according to a new AHRQ-funded study. Fault tree analysis has been used to reduce errors in high-risk nuclear, aerospace and chemical industries. To explore the usefulness of fault tree analysis in health care, researchers prepared fault trees for 10 patient case histories involving diagnostic errors. Those examples were then synthesized into a single fault tree to show common situations that can lead to diagnostic errors. Researchers found that the visual aspects of fault tree analysis provided a clear, unified illustration of the causes of diagnostic errors. Fault tree analysis also provided a framework for developing algorithms and computer software for the early detection of diagnostic errors, researchers concluded. The study, “Using Fault Trees to Advance Understanding of Diagnostic Errors,” and abstract appeared in The Joint Commission Journal on Quality and Patient Safety.
Jt Comm J Qual Patient Saf. 2017 Nov;43(11):598-605. doi: 10.1016/j.jcjq.2017.06.007. Epub 2017 Oct 2.
Using Fault Trees to Advance Understanding of Diagnostic Errors.
Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.