Healthcare Failure Modes

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Healthcare Failure Modes Effects Analysis
(HFMEA)Topic OR Fires

• presented to
• Surgical Services Advisory Board
• May 14, 2004

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I. Why did we choose this project?

• Internal incidents actual experience with fire
  in the OR at Evergreen
• Sentinel Event Alert (JCAHO) June 2003
• High risk event, high probability of
  financial/malpractice liability

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II. What did we learn?

• How to conduct an HFMEA.
• When we isolated sections of the fire triangle
  and did exhaustive review of all components we
  identified what contributes to increased fire
  risk.
• Identified three fire triangles with largest risk
  of failure and how to change process to impact
  safety and outcomes.

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III. High Risk Fire Triangles
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III. Key Failure Modes

• Lack of awareness
• Lack of education
• No Physician refresher course
• Staff review annually too infrequent

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IV. Recommendations

• Re-establish baseline Fire Safety knowledge for
  all OR Physicians and Staff
• Re-education via multiple channels
• Baseline fire drills/mock scenarios
• Awareness campaign
• Continue to certify OR Staff fire safety
  competency annually via EHMC annual safety
  education
• Certify Physician fire safety compentency
  bi-annually as part of re-credentialling process
  and upon initial membership of EHMC Medical Staff.