• Kamal Nagpal, Amit Vats, Kamran Ahmed, Andrea B Smith, Nick Sevdalis, Helgi Jonannsson, Charles Vincent, and Krishna Moorthy.
• Clinical Safety Research Unit, Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother Building, St Mary's Hospital, South Wharf Road, London W2 1NY, United Kingdom. k.nagpal@imperial.ac.uk
• Arch Surg. 2010 Jun 1;145(6):582-8.

HypothesisHealth care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures.DesignFailure mode and effect analysis.SettingAcademic research.ParticipantsA multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled.Main Outcome MeasuresA flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree.ResultsThe process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes.ConclusionsModified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.

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