ABSTRACT

Far from just being academic exercises, classifica­ tion of the types of failures that contribute to events often reveals information that becomes use­ ful in trying to rectify hazardous situations and con­ ditions. Whether retrospectively investigating the causes of an event or prospectively analyzing potential failures, determining steps to prevent future events seldom is clear. Sometimes analyses lead to many possible actions and selection of the one to take is needed. Other times, finding even a single corrective action remains elusive. In both cases, and those in between, classifying the failures and potential failures by various facets of their characteristics can provide guidance. This chapter considers failure classification systems: some his­ tory of their development, how they differ in their focus and procedures, and how they can contribute to reduction of risk to patients.