258862 Systematic Assessment in Child Protection: Learning from Drug Errors and Other Adverse Events

Monday, October 29, 2012 : 8:50 AM - 9:10 AM

Julie Taylor, PhD; MSc; BSc(Hons); RN , Strategy and Devlopment, NSPCC, London, United Kingdom
Gerry Armitage, PhD; BSc(Hons); RN , Bradford Teaching Hospitals, Bradford Health Care Research Institute, Bradford, United Kingdom
Laura Ashley, PhD; BSc(Hons); , Applied Informatics and Cancer Care Research Team, University of Leeds, Leeds, United Kingdom
Diane Jerwood, MA; RSW , Strategy and Devlopment, NSPCC, London, United Kingdom
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.

Learning Areas:
Conduct evaluation related to programs, research, and other areas of practice
Occupational health and safety
Other professions or practice related to public health
Public health or related nursing
Public health or related research
Systems thinking models (conceptual and theoretical models), applications related to public health

Learning Objectives:
1 Demonstrate an understanding of FMEA as a prospective risk assessment tool in the field of patient safety or quality improvement 2 Identify an understanding of designing and conducting a FMEA in both healthcare (medication safety), and social care (child protection) 3 Assess critically the utility and feasibility of implementing a FMEA in a time-limited public health or social care environment

Keywords: Child Abuse, Risk Assessment

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: Professor of Family Health at the University of Dundee, currently seconded to a UK national post as Head of Abuse in High Risk Families with the UKs largest child protection charity. I have a large portfolio of child protection research projects as principal investigator. I am the author of five books and numerous academic papers in child care and protection, and am a Fellow of the European Academy of Nursing Science.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.