Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Aug 2010
A practical guide to failure mode and effects analysis in health care: making the most of the team and its meetings.
Failure Mode and Effects Analysis (FMEA) is a proactive risk assessment tool used to identify potential vulnerabilities in complex, high-risk processes and to generate remedial actions before the processes result in adverse events. FMEA is increasingly used to proactively assess and improve the safety of complex health care processes such as drug administration and blood transfusion. A central feature of FMEA is that it is undertaken by a multidisciplinary team, and because it entails numerous analytical steps, it takes a series of several meetings. Composing a team of busy health care professionals with the appropriate knowledge, skill mix, and logistical availability for regular meetings is, however, a serious challenge. Despite this, information and advice on FMEA team assembly and meetings scheduling are scarce and diffuse and often presented without the accompanying rationale. ⋯ FMEA, generally acknowledged to be a useful addition to the patient safety toolkit, is a meticulous and time- and resource-intensive methodology, and its successful completion is highly dependent on the team members' aptitude and on the facility's and team members' commitment to hold regular, productive meetings.
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Jt Comm J Qual Patient Saf · Aug 2010
Reducing errors during patient-controlled analgesia therapy through failure mode and effects analysis.
Despite the technologic advances in design, resulting in the development of "smart" pumps to help deliver analgesia more safely, patient-controlled analgesia (PCA) is still involved in a significant proportion of the medication errors ascribed to intravenous (IV) drug administration, many of which have harmed patients. In 2003, Failure Mode and Effects Analysis (FMEA) was used to assess the PCA process at a 695-bed teaching and research tertiary hospital. IDENTIFYING AND ADDRESSING FAILURE MODES: For the three processes with hazard scores > 8--patient selection, prescribing, and medication administration-the potential cause(s) were identified, allowing the process to be redesigned to eliminate the potential cause(s). ⋯ Despite the reduction in PCA errors since the FMEA was conducted, misprogramming of drug concentration remains a common PCA error. Solutions include safety software for IV infusion pumps, an integral bar-code reader for detecting concentration errors, and interoperability of the software with other hospital information systems. One lesson learned was that an FMEA can lead to resolution of problems beyond the scope of original intent-in this case, the development of a new system for identifying all broken equipment.