Device Failure: Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of device failure, in addition clinical and system reviews to identify latent causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resource Introduction.
If your review reveals that your cases of device failure are linked to specific processes or procedures, you may find these resources helpful:
- Canadian Agency for Drugs and Technologies in Health (CADTH) https://www.cadth.ca/
- Canadian Patient Safety Institute
- Government of Canada www.Canada.ca
- Medicines & Healthcare Products Regulatory Agency (MRHA) Medicines and Healthcare products Regulatory Agency - GOV.UK www.gov.uk
- National Institute for Health and Care Excellence (NICE) www.nice.org.uk
- National Institute for Health and Care Excellence. Published guidance and advice. NICE Guidance. https://www.nice.org.uk/guidance/published?type=apg,csg,cg,cov,mpg,ph,sg,sc,dg,hst,ipg,mtg,qs,ta
- National Institute for Health and Care Excellence. Introducing techniques and medical devices. NICE Guidance: Local Practice. Published January 2013. https://www.nice.org.uk/sharedlearning/introducing-techniques-and-medical-devices
- National Institute for Health and Care Excellence. Medical Technologies Evaluation Programme. NICE guidelines. https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-medical-technologies-evaluation-programme
- World Health Organization (WHO) www.who.int