A Proactive Approach To Assess System Safety In Clinical Operations At A Comprehensive Cancer Center.

245 Background: Traditional approaches to improve safety in clinical operations focus on reacting to adverse events and intervening at the process level to prevent recurrence. A need exists to proactively explore safety at the system level and evaluate human factors that lead to errors. We developed and piloted a system safety assessment methodology to identify vulnerabilities in the Research Pharmacy at Dana-Farber Cancer Institute. Methods: We developed an interview tool based on the human factors analysis and classification system (HFACS) to obtain staff member perspectives on safety vulnerabilities. Detailed process maps were created for safety critical processes. Policies, procedures, and job aids were evaluated for effectiveness at preventing errors. Interfaces between the Research Pharmacy and other areas were studied to identify potential expectation misalignment. These elements formed a comprehensive methodology to proactively assess safety threats. Results: Based on our application of the assessment methodology, 16 system safety vulnerability themes were identified (table below) and 44 recommendations were generated to address them. From the recommendations, 26 improvement projects were proposed to prevent the occurrence of safety events. To date, 15 projects addressing 13 safety vulnerabilities have been initiated. Conclusions: Vulnerabilities uncovered through our methodology can inform the development of projects to proactively reduce risk and improve system resiliency in any clinical setting. Preliminary data indicate longer average days between safety events in the Research Pharmacy as projects triggered by the assessment are implemented. Further analysis is underway. [Table: see text]