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
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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
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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