A Practical Framework for Patient Care Teams to Identify and Mitigate Clinical Hazards

IDENTIFICATION: A primary AHRQ focus is to identify risks, hazards, and causes of patient injury associated with the delivery of health services. Indeed, one of the greatest challenges facing both practitioners and risk managers is the identification of previously unknown hazards. These threats to patient safety often lie at the apex of available knowledge and are rarely—if ever—obvious. With the rapid proliferation of new healthcare services, unknown hazards may propagate as new therapies are integrated into the existing healthcare system. The main goal of risk analysis is to make these hazards visible by proactively searching and probing the system. However, a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated. The objective of this Patient Safety Solution is to describe a framework that patient care teams can use to prospectively identify and mitigate potential hazards for patients and caregivers when introducing new therapies in the clinical setting. We conclude with a presentation of three case examples.