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Incident Investigation

A new tool for hazard analysis and force-field analysis: The Lovebug diagram

Alan J Card

Abstract Background: Fishbone diagrams have been widely promoted as a systems-focused hazard analysis tool for use in root

cause analysis, but they suffer from a number of structural weaknesses, including a unidirectional structure that only takes

into account forces that promote an accident (ignoring those that make the accident less likely or less severe) and a

means of displaying these forces that does not convey any difference in strength of influence. In a separate but related

issue, many healthcare organizations suffer from a lack of change management expertise.

Proposed solution: To address these concerns, I present a novel technique, the Lovebug diagram, which draws from

both Fishbone diagrams and force-field analysis (an approach to analyzing planned change). This new technique adds value

to both its progenitor methods, while retaining their key strengths and ease of use. It can be used both prospectively, to

assess planned changes, and retrospectively to assess unplanned (accidental) departures from the status quo.

Discussion: The Lovebug diagram is a more powerful analytical tool than its progenitor methods; however, overall

adoption of systems-focused tools for root cause analysis remains suboptimal. Additional research is needed to deter-

mine how best to promote a truly systems-focused approach to healthcare root cause analysis. Beyond this retrospective

use of the technique, it represents a simple tool to assist healthcare organizations with prospective change management.

Keywords

Safety management, risk assessment, risk management, organizational decision making, root cause analysis

Background

Fishbone diagrams (also known as Ishikawa diagrams or cause-and-effect diagrams) have been widely pro- moted as part of a suite of tools for use in root cause analysis (RCA). The Fishbone diagram is a systems-focused tool for assessing the causes and con- tributing factors (CCFs) that played a role in an adverse event or near miss.

1–6 This workshop-based

tool takes its name from its characteristic shape: As seen in Figure 1, the adverse event is shown on the right; the ‘‘spine’’ of the Fishbone diagram depicts the combined influence of CCFs on that adverse event; boxes labeling different categories of CCFs are connected to the spine via diagonal lines; and the spe- cific incidences of those CCFs are attached horizon- tally to the appropriate diagonals. Subcauses can be attached to these CCFs, if required. The Fishbone dia- gram in Figure 1 is used to provide a high-level view of the CCFs related to an incident, but it is worth noting that, where the additional time investment is feasible, the analytical power of the tool is increased when it is

used at a more detailed level to address each care/ser- vice delivery problem identified.

By helping users identify these CCFs, the Fishbone diagram is intended to point out vulnerabilities that can be addressed to make the system safer. In terms of the famous Swiss Cheese model of accident causation,

7 it

helps users to visualize the holes that lined up to allow harm to propagate through the system.

The example in Figure 1 takes its category headings from the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety

8 and describes the hypothetical case of a

wrong-dose medication error in a community hospital. While the SEIPS model is used here, any number of

Evidence-Based Health Solutions, LLC, Notre Dame, USA

Corresponding author:

Alan J Card, Evidence-Based Health Solutions, LLC, PO Box 62, Notre

Dame, IN 46556, USA.

Email: [email protected]

Clinical Risk

19(4–5) 87–92

! The Author(s) 2013

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DOI: 10.1177/1356262213510855

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additional frameworks could be used, such as those proposed by Vincent,

9 Rasmussen,

10 or Runciman

et al. 11

As the figure illustrates, potential CCFs related to the technology and tools component or the SEIPS model include the fact that the computerized physician order entry (CPOE) system produces too many alert messages, as well as the fact that it is too easy to over- ride those messages, even when they relate to serious overdoses. The category headings (technology and tools, organization, person, tasks, environment, and process) serve not only as a way of organizing identified CCFs but also as an aid in identifying them.

Treating the category headings as prompts, users can employ the Fishbone diagram as the basis of a struc- tured brainstorming method, similar to other such tech- niques, including the Structured What-If Technique (SWIFT),

12 Generating Options for Active Risk

Control (GO-ARC) technique, 13

or Hazard and Operability Studies (HAZOP).

14,15 Fishbone diagrams

can also be used to supplement more tightly-focused risk assessment techniques such as fault tree analysis (FTA).

16 FTA is quite powerful, but it addresses only

those causes that would lead deterministically to an adverse event; it is not capable of assessing contributing

factors, which is a key strength of the Fishbone dia- gram. Other key strengths of the Fishbone diagram include its focus on systems-level causes, rather than individual failings, along with the fact that it is easy to use and that its graphical nature makes it easy to understand at a glance.

2

But the technique suffers from a significant structural weakness. Fishbone diagrams are unidirectional; that is, they depict only the CCFs that may have promoted an adverse event (or near miss). They ignore the other half of the picture: The forces that operated to reduce the likelihood or severity of the adverse event. An emergent strand of research in systems safety highlights the importance of resilience in the form of ‘‘error recovery opportunities’’

17 that may enable those involved in an

emerging incident to ‘‘stop the error cascade.’’ 18

More broadly, a full understanding of what went wrong also requires an understanding of what went right. Such an understanding can answer questions like: ‘‘Which bar- riers to harm did not fail?’’ ‘‘Might these robust barriers serve as the foundation for further improvement?’’ and ‘‘Which aspects of the existing system should be retained (or at least changed with care) when redesign- ing the system to improve safety?’’

Technologies & tools

Organization Person

ProcessEnvironmentTasks

Wrong dose medication error in a

community hospital

Too many alerts in CPOE system led to habit of immediately overriding them

Easy to override alerts, even for serious overdoses

Unusually high patient load for time of day

Float nurse prepared the dose; not familiar with unit, treatment protocols

Doctor declined to revise dose

High level of autonomy for doctors; low level of autonomy for nurses

Reduced staffing at night; only doctor on-site was busy elsewhere

Layout of hospital / staffing level combined to leave the nurse working in relative isolation

Doctor was driving home in bad traffic when asked to clarify dose

Doctor seldom ordered this medication

Nurse did not feel confident enough to go over doctor’s head

Dose prepared by nurse, not by pharmacy or manufacturer

Lack of a non- adversarial process for questioning the dose after the doctor declined to change it

Figure 1. A Fishbone diagram based on the SEIPS model 8

examining a wrong-dose medication error in a community hospital.

88 Clinical Risk 19(4–5)

This paper addresses this weakness by introducing a new approach to mapping the forces influencing an adverse event or near miss; it also describes how the same approach can be used to assess a planned chan- ge—including not only risk control action plans but also more general plans like the implementation of a new electronic health record (EHR) system.

Proposed solution: The Lovebug diagram

The Lovebug diagram (Figure 2) extends the Fishbone diagram by mapping the influences both for and against an event occurring. As with the Fishbone diagram, it is named for its resemblance to a shape from nature: in this case, a mating pair of Plecia nearctica, commonly known as Lovebugs. The left side of a Lovebug dia- gram is the same as a Fishbone diagram and depicts the forces that make an event more likely. The right side of the diagram is laid out as a mirror image of the left and is populated with the forces that make an event less likely. Thus, where the left side serves as a starting point for hazard analysis, the right side serves as a starting point for barrier analysis (albeit without necessarily tying the barriers to discrete cause- consequence pairs, as in traditional barrier analysis).

2,19

Figure 2 expands upon the incident shown in Figure 1. In this scenario, a wrong-dose drug error occurred, but caused only temporary harm because the nurse preparing and administering the medication was monitoring the patient closely out of a concern that

the dose might be too high. As a comparison of Figures 1 and 2 demonstrates, the Lovebug diagram presents a far more comprehensive view of the incident than the Fishbone diagram alone. It gives critical infor- mation about the error recovery opportunities that could have (or did) ameliorate the harm cased by the initial error. Thus, in addition to informing efforts to reduce the likelihood of the initial error, it also provides a starting point for strengthening or adding barriers to reduce harm if the initial error does occur.

A useful feature of the diagram’s layout is that forces working for and against an event are presented as mirror images. In Figure 2, for instance, it is clear that the error recovery opportunity presented by the overdose alert in the CPOE system was counterba- lanced by a low signal-to-noise ratio for alerts, which led the doctor to develop a habit of overriding alerts without reading them closely. Among the risk controls that might arise from this insight would be strengthen- ing this error recovery opportunity by (a) making it more difficult (if not impossible) to override an obvious overdose and (b) reducing the number of extraneous alerts requiring an override.

Other resilience-focused risk control options sug- gested by the right side of the diagram (and its inter- action with the left side) include: training nurses normally on the unit to recognize the normal dosing range for this drug, as well as signs and symptoms of overdose; establishing a formal rapid response team

20

protocol (and ensuring that it can function at

Tasks EnvironmentProcess

Person Organization Technologies & toolsTechnologies

& tools Organization Person

ProcessEnvironmentTasks

Causes and Contributing Factors Barriers

Wrong dose medication error in a

community hospital

Too many alerts in CPOE system led to habit of immediately overriding them

CPOE alerted doctor to overdose

Easy to override alerts, even for serious overdoses

Nurse did not feel confident enough to go over doctor’s head

High level of autonomy for doctors; low level of autonomy for nurses

Doctor was driving home in bad traffic when asked to clarify dose

Doctor declined to revise dose

Reduced staffing at night; only doctor on-site was busy elsewhere

Unusually high patient load for time of day

Dose prepared by nurse, not by pharmacy or manufacturer

Float nurse prepared the dose; not familiar with unit, treatment protocols

Nurse was familiar with the drug from her regular unit

Nurse increased frequency of observation for this patient out of concern about the dose

Layout of hospital / staffing level combined to leave the nurse working in relative isolation

Nurse identified dose as questionable and contacted doctor for clarification

Some additional staff on site were able to respond to the emergency when the patient began exhibiting signs of overdose

Unit layout allowed nurse to check on patient frequently while continuing to care for other patients

Nurse knew clinical signs / symptoms of overdose

Doctor seldom ordered this medication

Lack of a non- adversarial process for questioning the dose after the doctor declined to change it

Nurse identified overdose in time to prevent permanent harm to patient

Figure 2. A Lovebug diagram based on the SEIPS model 8

examining a wrong-dose medication error in a community hospital.

Card 89

night-time staffing levels) to ensure that calling in help from other units works as well next time; implementing a structured communication approach

21 to assist nurses

in communicating concerns in a way more likely to result in the right response; promotion of ‘‘when you have to proceed, but still have doubts, monitor the patient closely’’ as an important error recovery strategy.

Obviously, the right side of the Lovebug diagram alone is not sufficient; some of the risk controls for this case should also be drawn from the error- promoting side of the diagram (e.g. 24-h hospitalist coverage, and use of the hospitalist as the source for a second opinion when nurses have called for clarifica- tion but still have doubts; adoption of unit dosing for high-risk medications, etc.). But it is likely that few of the risk controls suggested by the resilience-promoting side of the diagram would have arisen from an analysis of the error producing side alone. Both error-promot- ing and resilience-promoting factors must be con- sidered for a complete picture of what happened and how harm can be prevented (or reduced) in the future.

The Lovebug diagram as a tool for force field analysis

The Lovebug diagram may also be useful beyond the context of incident analysis. Specifically, it may help users to analyze the forces or factors operating for and against a planned change, whether that change is a small-scale risk control intervention (e.g. the redesign of a specific clinical process in the wake of an incident) or a large-scale, organization-wide intervention like the adoption of a new EHR system.

This broader remit for the Lovebug diagram stems from the fact that the tool’s bi-directional design is drawn from force-field analysis, a tool for managing planned change.

22,23 Force-field analysis is based on

Kurt Lewin’s Field Theory, which posits that the status quo is the product of a semi-stable, but dynamic equilibrium of forces acting for and against change.

24

Achieving a planned change, therefore, requires an increase in the forces acting in favor of a change and/or a reduction in the forces acting against it. As Figure 1 illustrates, this same framework can also be used for assessing unplanned deviations from the status quo, as in the case of accidents or near misses. When barriers that normally prevent accident fail, for instance, the net force acting against that accident is decreased, which may shift the equilibrium toward an undesired state.

There is some variation in how force-field analyses are diagrammed, but the example in Figure 3 is typical. Note that arrows of different sizes correspond to forces of different strengths; larger arrows represent stronger forces and smaller arrows represent weaker forces.

The Lovebug diagram can also reflect the strength of individual forces through the use of different font sizes or styles. Figure 4 shows a Lovebug diagram examining the forces for and against the success of a new EHR system in a physician practice; the strongest forces are in a bold font; medium forces are in italics, and weaker forces are in a smaller sized font. This can be under- stood at a glance, quite intuitively. The category head- ings in this case are drawn from the Theory of Organizational Readiness for Change.

25

As Figure 4 shows, the utility of the Lovebug dia- gram is not limited to RCA; it can also be used to assess planned change. A lack of change management expert- ise has been identified as a problem in the healthcare sector.

26 As a change management tool, the Lovebug

diagram could also be applied to the analysis of risk controls (interventions to reduce risk), thus contribut- ing to both the problem exploration (risk assessment) and problem-solving (risk control) components of the

Strong force against change Strong force in favor of change

Moderate force in favor of change Moderate force against change

Weak force against changeWeak force in favor of change

Brief description of the planned

change

Figure 3. A force-field analysis.

90 Clinical Risk 19(4–5)

risk management process—and perhaps leading to the adoption of stronger,

27 more implementable,

28 and

more acceptable 29

risk controls than results from cur- rent practice.

Discussion

The Lovebug diagram retains the strengths and ease of use of both its progenitors; anyone who is familiar with Fishbone diagrams or force-field analysis should be able to adapt to using the Lovebug diagram without any difficulty. This new approach adds value to both approaches, first as extension of Fishbone diagrams that allows for bidirectional, force-field-style analysis, and second a means of imposing a useful structure on force-field analysis (which does not typically benefit from a structured, framework-based approach). It also includes an innovation to improve both Fishbone and Lovebug diagrams: the use of different fonts to reflect stronger and weaker forces. Finally, adding a focus on evidence of good practice may both reduce the negative impact that incident investigations can have on staff morale and also avoid giving an unduly negative impression of the organization to external audiences.

30

Unlike some tools that support structured brain- storming (e.g. the SWIFT

12 ), the Lovebug diagram

also employs its prompts as means of categorizing and organizing the CCFs for action. For this reason, it is probably worth using a well-established framework

as the basis for a Fishbone diagram. This paper pre- sented examples using the SEIPS framework

8 and the

Theory of Organizational Readiness for Change, 25

but, as described earlier, there are many other frameworks available

9–11 ; the goal should be to select a framework

that is well suited to both the problem and the organ- ization within which it is situated. Because frontline workers should be involved in using the Lovebug dia- gram (and thus the chosen framework), key consider- ations for selecting a framework should focus not only on the framework’s conceptual robustness but also on the degree to which it can be understood by non-spe- cialists with a practical amount of training.

While the Lovebug diagram represents an advance in existing practice versus Fishbone diagrams and force field analysis, it is worth noting that some research

26,31

and much anecdotal evidence suggests that the use of such systems-focused risk assessment techniques in healthcare RCA may not be as common as practice guidelines

1–5 might imply. Where it is used, the

Lovebug diagram should enable users to conduct a more comprehensive analysis of patient safety inci- dents, but additional research is needed to determine how best to promote the uptake of a truly systems- focused approach to healthcare RCA.

Conclusion

The Lovebug diagram is a novel approach to hazard analysis and the assessment of planned change.

Resource perceptions

Situational factors

Task demands Change valenceChange

valence Task demands

Situational factors

Resource perceptions

Financial incentives for “meaningful use”

Patient expectations

Hope that the EHR system will improve quality & safety

Current process viewed as cumbersome, out of date

Onsite tech support for first 2 weeks

Reduced patient load for first 2 weeks

Senior management support

No significant pre- implementation training; will need time to learn new system

Need to redesign workflows to accommodate new system

System is already paid for; must be made to work

No money to change to a new system if this one does not work

Poor usability

Skepticism that this is the right system for the job

Concern that workflow changes made to accommodate the EHR system may impair quality & safety

Insufficient time/money invested in high-quality pre-implementation training

Even with reduced patient load, not enough slack time to learn new system

Tech support inadequate

Frustration with poor system design / inadequate training

Low morale due to feared job losses if patient load cannot be increased

Patients frustrated by delays and mistakes during transition

Frontline workers not consulted during EHR acquisition process

Causes and Contributing Factors Barriers

Successful implementation of a new off-the-shelf

EHR system

Figure 4. A Lovebug diagram for assessing a planned change based on the Theory of Organizational Readiness for Change. 25

Card 91

A hybrid of the Fishbone diagram and force-field ana- lysis, it depicts the forces that operate both for and against the occurrence of a change from the status quo (whether planned or accidental). Through the use of category headings, it also provides a structured approach to brainstorming and analyzing these forces. While the Lovebug diagram represents a step forward for current practice in the use of both Fishbone dia- grams and force-field analysis, overall uptake of sys- tems-focused tools for healthcare RCA may lag behind practice guidelines. Additional research is needed to determine how best to promote the uptake of a truly systems-focused approach to health- care RCA.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The author declares no conflict of interest.

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