Using failure modes and effects analysis to evaluate

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Using failure modes and effects analysis to
evaluate home meds failures in surgical patients

• Fred M. Blanchard, Pharm.D.
• Virginia Commonwealth University
• Patient Safety Fellowship Program
• May 1, 2003

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Purpose

• Introduce FMEA methodology
• Incorporate FMEA into Performance Improvement and
  Patient Safety Efforts
• Apply FMEA and evaluate home meds failures

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Methods

• Establish a team
• FOCUS PDSA
• FMEA Training
• FMEA
• Define, Prioritize, Measure Failures
• Intervene
• Re-measure

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Home Meds Team

• Dale Bosiger, Pre-op Education
• Debra Coulter, PACU
• Lynn Harris, Surgicare
• Nadine Gilmore, Pharmacy
• Linda Lange, Nursing Policy and Procedure

• Sherry Payne, Orthopedic Unit
• Randall Puckett, Pharmacy
• Kim Woodley, Quality Support Services (PI)
• Fred Blanchard, Pharmacy

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FMEA

• Originally intended for prospective
  identification of failures
• Applied retrospectively as a stand alone process
  in the healthcare environment
• Also applied as a tool in FOCUS PDSA

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PI and FMEA Similarities

• FOCUS PDSA
• Find a Challenge
• Organize a Team
• Clarify Process
• Understand the Variation Select a Process
• P-D-S-A

• FMEA
• Define Topic
• Assemble Team
• Describe Process
• Hazard Analysis
• Action/Outcome Measures

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Graphic Description of Process
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Subsystem Steps and Causes
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Failure Mode

• 2g1 Nurse transcription from patient form to
  assessment sheet is illegible

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Failure Analysis
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Potential Cause

• 2g1(e) Form not suitable for writing complete
  medication instructions including drug, strength,
  route, and frequency

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Hazard Analysis 2g1(e)

• Severity Major
• Probability Frequent
• Hazard Score 12

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Decision Tree 2g1(e)
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Action Type

• Control
• Accept
• Eliminate

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Action and Outcome Measures

• Measure error rates at baseline
• Develop a new form combine steps
• Perform a trial
• Measure post intervention error rates

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P R E O P N U R S E A D M I T R E C O R D


O L D F O R M
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Baseline Measure of Current Process

• Retrospectively reviewed 94 charts-all same day
  surgeries over a three week period

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Baseline Measurements
Before
Charts with Home Meds documented pre-op 94
Charts with any order to renew Home Meds post-op 69
Post-op Home Meds order qualified 84
Post-op Home Meds orders complete 34
Post-op orders that were clarified 44
Average number of Home-Meds pre-op 5.7
Average number of Home Meds renewed post-op 2.7
Drug, Strength, Frequency, Route info pre-op 91
Drug, Strength, Frequency, Route info post-op 98
Discrepancies post-op 22
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R E S U M E H O M E M E D S F O R M

N E W F O R M
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Post Intervention Utilization of Combined Home
Meds Form

• Retrospectively reviewed 51 charts-all same day
  surgeries over a two week period
• New form used by nursing staff 45 times (88)
• New form used by nursing and physician staff 35
  times (78)

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Results
Before After
Charts with Home Meds documented pre-op 94 100
Charts with any order to renew Home Meds post-op 69 100
Post-op Home Meds order qualified 84 100
Post-op Home Meds orders complete 34 100
Post-op orders that were clarified 44 0
Average number of Home-Meds pre-op 5.7 6.3
Average number of Home Meds renewed post-op 2.7 4.9
Drug, Strength. Frequency, Route info pre-op 91 99
Drug, Strength, Frequency, Route info post-op 98 99
Discrepancies post-op 22 0
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Discussion

• Advantages of using FMEA in the context of FOCUS
  PDSA
• Identification of failures
• Greater depth of analysis
• Improved prioritization of selected processes
• Limitations
• Time consuming
• Reserve for critical processes

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Discussion

• Home Meds Reorder Process
• Combining pre-op medication history with post-op
  order set
• Reduced process variation
• Improved pre-op documentation
• Increased frequency of post-op renewal
• Improved the completeness of post-op orders
• Reduced calls to clarify orders
• Increased probability that meds taken at home
  were continued post-op
• Reduced the number of post-op order discrepancies