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Healthcare Failure Mode and Effect Analysis SM Edward J. Dunn, MD, MPH VA National Center for Patient Safety

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Presentation on theme: "Healthcare Failure Mode and Effect Analysis SM Edward J. Dunn, MD, MPH VA National Center for Patient Safety"— Presentation transcript:

1 Healthcare Failure Mode and Effect Analysis SM Edward J. Dunn, MD, MPH VA National Center for Patient Safety edward.dunn@med.va.gov www.patientsafety.gov

2 Location in our VA NCPS Curriculum Toolkit Content - Patient Safety Introduction - Human Factors Engineering -HFMEA ppt & exercise Alternative Education Formats - Pt Safety Case Conference (M&M) - Pt Safety on Rounds (Modulettes) - HFMEA participation - Etc… Instructor Preparation -Swift and Long Term Trust - Selling the Curriculum - Etc…

3 Aimed at prevention of adverse events Doesn t require previous bad experience (patient harm) Makes system more robust JCAHO requirement Why use prospective analysis?

4 JCAHO Standard LD.5.2 Effective 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

5 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

6 Healthcare Version - HFMEA SM 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)

7 The Healthcare Failure Mode Effect Analysis Process Step 2 - Assemble the Team Step 3 - Graphically Describe the Process Step 4 - Conduct the Analysis Step 5 - Identify Actions and Outcome Measures Step 1- Define the Topic

8 HFMEA TM Hazard Scoring Matrix Probability Severity CatastrophicMajorModerateMinor Frequent161284 Occasional12963 Uncommon8642 Remote4321

9 HFMEA TM Decision Tree Does this hazard involve a sufficient likelihood of occurrence and severity to warrant that it be controlled? (e.g. Hazard Score of 8 or higher) Is the hazard so obvious and readily apparent that a control measure is not warranted? (Detectability) STOP NO YES PROCEED TO HFMEA STEP 5 NO Does an Effective Control Measure exist for the identified hazard? YES NO Is this a single point weakness in the process? (e.g. failure will result in system failure) (Criticality) YES NO

10 ICU Alarm Example

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13 Blow-up of One Line Ignored alarm (desensitized) Catastr ophic FrequentReduce 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 Failure Mode: 3B1a - Crucial Alarm Ignored and Patient Decompensated Failure Mode Cause Severity Outcome Measure Frequency Action

14 HFMEA & RCA Interdisciplinary team Develop flow diagram Systems focus Actions & Outcome measures Scoring matrix (severity/probability) Triage questions, cause & effect diag., brainstorming 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 Similarities Differences


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