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.
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Jt Comm J Qual Patient Saf · Jul 2010
Patient safety climate in hospitals: act locally on variation across units.
An appreciation of how human factors affect patient safety has led to development of safety climate surveys and recommendations that hospitals regularly assess safety attitudes among caregivers. A better understanding of variation in patient safety climate across units within hospitals would facilitate internal efforts to improve safety climate. A study was conducted to assess the extent and nature of variation in safety climate across units within an academic medical center. ⋯ Safety climate may vary markedly within hospitals. Assessments of safety climate and educational and other interventions should anticipate considerable variation across units within individual hospitals. Furthermore, clinicians at individual hospitals may offer different relative perceptions of the safety climate than their professional peers at other hospitals.
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Jt Comm J Qual Patient Saf · Jul 2010
How I nearly MET my maker: a story of clinical futile cycles and survival.
In this series, the articles have highlighted a variety of implementation methods and uses of rapid response systems (RRSs). They have described how RRSs have been uniquely tailored to the organizations' culture and clinical environments, with largely positive results following implementation. In this article, Dr. ⋯ Furthermore, it must be implemented and operated in the context of the hospital's organizational culture. Although the administrative and quality improvement arms of the RRS are often underemphasized, this story exemplifies their importance--not just for RRSs but indeed for all hospital systems. The author, one of the leading proponents of rapid response systems worldwide, recounts his own close-call experience, in which he found himself in what he terms a clinical futile cycle.
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Jt Comm J Qual Patient Saf · Jun 2010
Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit.
A culture of teamwork and learning from mistakes are universally acknowledged as essential factors to improve patient safety. Both are part of the Comprehensive Unit-based Safety Program (CUSP), which improved safety in intensive care units but had not been evaluated in other inpatient settings. ⋯ Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on a surgical inpatient unit after implementing a safety program. As part of the CUSP process, staff described safety hazards and then as a team designed and implemented several interventions. CUSP is sufficiently structured to provide a strategy for health care organizations to improve culture and learn from mistakes, yet is flexible enough for units to focus on risks that they perceive as most important, given their context. Broad use of this program throughout health systems could arguably produce substantial improvements in patient safety.