Using Failure Mode Effects and Criticality Analysis for High-Risk Processes at Three Community Hospitals
Abstract:Background: An applied research firm collaborated with staff at three community hospitals to apply Failure Mode Effects and Criticality Analysis (FMECA) to reduce the occurrence of adverse events associated with high-risk processes. The collaboration team, which developed its own FMECA approach, performed FMECAs for six processes, including prevention of patient falls, correct medication ordering and delivery of solid oral medication, and correct blood type transfusion for adult medical surgery patients.
Development of FMECA Procedure and Tool: The hospitals followed eight specific steps to gather data, conduct FMECA sessions, and identify medical process weaknesses and risk reduction measures. Worksheets, including each step of the system process, success criteria, possible failure modes, causes of failure, frequency of failure, consequence of failure, and safeguards placed to avoid failure, were used to capture information during the FMECA sessions.
Conclusions: On the basis of identified weaknesses, along with cost and other administrative considerations, medical process improvements were devised. Rules for devising improvements included improvements that help prevent the failure mode were better than those that mitigate the consequences, passive features that prevent failures were better than administrative controls, and improvements with the highest reliability were favored.
Document Type: Research Article
Publication date: March 1, 2005
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- Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.
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