Healthcare Failure Mode and Effect AnalysisSM

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Healthcare Failure Mode and Effect AnalysisSM

• Edward J. Dunn, MD, MPH
• VA National Center for Patient Safety
• edward.dunn_at_med.va.gov www.patientsafety.gov

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Location in our VA NCPS Curriculum Toolkit

• Content
• Patient Safety Introduction
• Human Factors Engineering
• HFMEA ppt exercise

• Instructor Preparation
• Swift and Long Term Trust
• Selling the Curriculum
• Etc

• Alternative Education Formats
• Pt Safety Case Conference (MM)
• Pt Safety on Rounds (Modulettes)
• HFMEA participation
• Etc

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Why use prospective analysis?

• Aimed at prevention of adverse events
• Doesnt require previous bad experience (patient
  harm)
• Makes system more robust
• JCAHO requirement

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JCAHO Standard LD.5.2Effective July 2001
Leaders ensure that an ongoing, proactive program
for identifying risks to patient safety and
reducing medical/health care errors is defined
and implemented.

• Identify and prioritize high-risk processes
• Annually, select at least one high-risk process
• Identify potential failure modes
• For each failure mode, identify the possible
  effects
• For the most critical effects, conduct a root
  cause analysis

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Who uses failure mode effect analysis?

• Engineers worldwide in
• Aviation
• Nuclear power
• Aerospace
• Chemical process industries
• Automotive industries
• Has been around for over 40 years
• Goal has been, and remains, to prevent accidents
  from occurring

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Healthcare Version - HFMEASM

• Combines
• Traditional Failure Mode Effect Analysis
• Hazard Analysis and Critical Control Point
• VA Root Cause Analysis
• Adapted and Tested in Healthcare Settings
• 163 VA hospitals (with some success)
• Still a complex process/time commitment (see NIH)

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The Healthcare Failure Mode Effect Analysis
Process
Step 1- Define the Topic
Step 2 - Assemble the Team
Step 3 - Graphically Describe the Process
Step 4 - Conduct the Analysis
Step 5 - Identify Actions and Outcome Measures
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HFMEATM Hazard Scoring Matrix
Probability Severity Severity Severity Severity Severity
Probability Catastrophic Major Moderate Minor
Probability Frequent 16 12 8 4
Probability Occasional 12 9 6 3
Probability Uncommon 8 6 4 2
Probability Remote 4 3 2 1
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HFMEATM Decision Tree
     
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ICU Alarm Example
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ICU Alarm Example
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ICU Alarm Example
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Blow-up of One Line
Failure Mode 3B1a - Crucial Alarm Ignored and
Patient Decompensated

Failure Mode Cause
Outcome Measure
Action
Severity
Frequency
Ignored alarm (desensitized) Catastrophic Frequent Reduce unwanted alarms by changing alarm parameter to fit patient physiological condition and replace electrodes with better quality that do not become detached Unwanted alarms on floor are reduced by 75 within 30 days of implementation
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HFMEA RCA
Differences
Similarities

• Preventive v. reactive
• Analysis of Process v. chronological case
• Choose topic v. case
• Prospective (what if) analysis
• Detectability Criticality in evaluation
• Emphasis on testing intervention

• Interdisciplinary team
• Develop flow diagram
• Systems focus
• Actions Outcome measures
• Scoring matrix (severity/probability)
• Triage questions, cause effect diag.,
  brainstorming