Systematic Assessment in Child Protection: Learning from Drug Errors and Other Adverse Events

Objective To examine the use of Failure Modes and Effects Analysis (FMEA) as a mechanism for identifying and reducing decision making error when undertaking risk assessments with families who have multiple and complex problems. FMEA, a systems approach developed exponentially by military, engineering, space and manufacturing programmes, recently has been adapted for use within healthcare. FMEA is a prospective quality assurance methodology to examine potential process failures, evaluate risk priorities and determine remedial actions.

Methods Building on work undertaken within health care on drug medication errors, we explore the methodological techniques of FMEA as applied within child protection. We demonstrate how research can usefully draw on quality assurance techniques and apply them in real world settings where complex decisions with potentially life-threatening outcomes can be influenced. We have applied the explicit methods of FMEA to a range of complex child protection cases.

Results Within child protection, FMEA has the potential to examine meticulously the assessment process and how it develops within a case, using this analysis as a building block to understanding strengths and weaknesses in the system more broadly in order to make improvements.

Conclusion Given the lessons from biennial analyses of serious case reviews it is clear that there is much still to improve within the child protection system. FMEA offers an alternative systems methodology that is built on human factors that are frequently implicated in serious case reviews. The patient safety techniques that are successful within healthcare can be applied usefully within the child protection system.