Ottawa Childrens Treatment Centre Failure Mode and Effects Analysis FMEA Code Yellow Missing Child

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Ottawa Childrens Treatment CentreFailure Mode
and Effects Analysis (FMEA)Code Yellow (Missing
Child)

• Sharon Lefroy and
• Ann Marcotte
• October 21, 2008

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Purpose of this session

• By the end of this session participants will
  be more familiar with
• The FMEA tool which can be used to fulfill the
  Accreditation Canada requirement for a patient
  safety-related, prospective, analytical process
• Be acquainted with strategies for managing a
  situation involving a missing person

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Patient safety-related prospective analysis

• Accreditation Canada requires organizations to
  carry out one patient safety-related,
  prospective, analytical process per year and to
  implement improvements or changes in response to
  the findings.
• Failure mode and effects analysis is one form of
  prospective analysis that can be used to achieve
  this end.

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What is Failure Mode Effects Analysis (FMEA)?

• Failure mode and Effects Analysis (FMEA) is a
  team-based, systematic approach used to identify
  the ways that a process or design can fail, the
  effects of that failure and how it can be made
  safer.

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The History of FMEAs
Military strategy Aerospace design Automobile
safety and regulations Other industries
including health care
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When is Failure Mode and Effects Analyses used?

• FEMA is used
• During early design stage of a new product,
  process or system
• As part of the Continuous Quality Improvement
  Process
• To identify/evaluate/ address overall
  organizational risks
• To prevent or mitigate the impact of a potential
  system failure.

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Steps in the Failure Mode and Effects Analysis
process
Repeat process
Assess impact
Make improvements
Prioritize failure modes
Identify causes
Identify failure modes
Sketch the process
Assemble the team
Define a Topic

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Step 1- Choose A Topic Code Yellow (missing
client)

• Why study Code Yellow?
• A high risk situation with potentially serious
  consequences
• Increasing numbers of clients with communication
  and behavioral issues
• Code Yellow management is a complex process
  requiring a rapid, coordinated effort

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The challenges of a missing client in a complex
physical environment
 
 
 
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Step 2 Assemble the FMEA team

• The OCTC FMEA Code Yellow Team
• Chair, Quality-Risk Committee
• Supervisor, Preschool
• Principal, School
• Nurse, Out of Home Respite
• Recreation Therapist
• Dir. Client Programs Info
• Director, Finance Facilities' Pl.
• Special Projects Coordinator
• Prog. Admin., Early Childhood
• Head of Security, CHEO
• Plus input from all other staff at education
  sessions

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Important to carefully define the issue

• What is a missing person?
• What are the different conditions under which a
  search might have to occur??

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Step 3 Sketching out the Process

• Develop a decision tree based on possible
  scenarios and stages in the process
• Support the process with associated policies and
  procedures
• Check the process against staff members outside
  the team

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Core outline of Code Yellow decision tree

• Client
• missing

Stage I Alert- Search immediate area
Client not found Low risk
Client not found- High risk
Stage II Alert- Search Inside building
Stage III Alert- Search inside and outside
building
Client not found
Client not found- call 911
Client found. Search over
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Step 4 Identify the Failure Modes (what can go
wrong during the process)

• Failure modes are generated based on projected
  worst-case scenarios and are developed around
  general themes.
• Identified themes as part of the OCTC Code
  Yellow FMEA include human, equipment and
  environmental factors.

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Step 5- Identifying the causes of Failure Modes
Digging a little deeper

• Committee members were then asked to consider
  potential causes of each of the identified
  failure modes of people, equipment and
  environmental factors.
• Potential causes fell under the general
  categories of
• 1. Best practice
• 2. Communication and
• 3. Delays

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Examples of each failure mode and associated
identified causes
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Step 6 Set priorities between failure modes
Then Calculate the product, Impact Frequency
Risk of failure

• Assess the impact
• Low 1
• Moderate 2
• High 3
• Critical 4
• and Frequency level
• Rare 1
• Unlikely 2
• Possible 3
• Likely 4
• Almost certain 5

And weigh against other failure modes
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Examples of failure modes assessed by risk level
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Failure Mode Analysis OCTC Code Yellow Findings

• The risk of failure is higher in human than
  environmental or equipment factors.
• The potential for human error is highest in the
  following
• Failure to act quickly or decisively
• Failure to conduct a sufficiently thorough search
• Failure to understand roles and responsibilities
  during a code yellow

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Step VII- Redesign the Process (Error Prevention
Strategies)
Task force members were asked to consider the
risks of the various failure modes and to
determine low and high leverage risk reduction
and mitigation strategies for the Code Yellow
process
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Step VII- Redesign the Process using error
prevention strategies (continued)

• Lower leverage strategies for Code Yellow
  include
• Disseminate the information through corporate
  newsletter
• Mirror code yellow to existing code red as
  possible
• Include codes on identification badge
• Post signage near phones
• Use checklists

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Step VII- Redesign the Process using error
prevention strategies (continued)

• High leverage strategies include
• Assign lead responsibility for education, mock
  trials to one person
• Designate responsibilities to specific
  individuals
• Include code yellow in staff orientation and
  education sessions
• Hold regular mock codes
• Incident reports and follow-up action
• Develop policies and procedures for each site
  and for off hour and off site activities

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Step 9 Analyze and test the changes (Evaluation)

• Following a mock trial or actual event
• Complete a comprehensive report on what worked
  and what did not work
• Review and revise Code Yellow policies and
  procedures to incorporate required changes
• Provide staff with feedback and information on
  the policy updates
• Repeat FMEA process and work to decrease risk
  priority numbers

Looking ahead
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References

• The Basics of Healthcare Failure Mode and Effect
  Analysis, Videoconference Course, presented by VA
  National Center for Patient Safety
• Bloorview Kids Rehab, FMEA exercise, 2007.

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Thanks to the FMEA team for their work!Thank
you for your attention!

• Any questions?