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Failure mode and effect analysis: an application in reducing risk in blood transfusion
1Good Samaritan Hospital, 2222 Philadelphia Drive, Dayton, OH 45406, USA. Jburgme@shp-dayton.org
The Joint Commission Journal on Quality Improvement
|June 18, 2002
Summary
Failure Mode and Effect Analysis (FMEA) improved blood transfusion safety by identifying and mitigating risks. This systematic approach prevented serious errors, demonstrating its value for high-priority healthcare processes.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety
- Risk Management
Background:
- Good Samaritan Hospital implemented a Failure Mode and Effect Analysis (FMEA) in February 2001 to enhance the blood transfusion process.
- The FMEA involved identifying failure modes, causes, and effects, assigning risk priority numbers (RPNs), and developing solutions.
Purpose of the Study:
- To reduce risks and prevent errors within the hospital's blood transfusion procedure.
- To implement and validate process redesigns based on FMEA findings.
Main Methods:
- Conducted a Failure Mode and Effect Analysis (FMEA) to systematically identify potential failures in the blood transfusion process.
- Assigned numerical scores for occurrence, severity, and detection to calculate Risk Priority Numbers (RPNs).
- Developed and implemented process redesigns, including a blood barrier system, based on high RPNs.
Main Results:
- Implemented design changes, such as a patient-specific code access blood barrier, were approved by the Safety Board.
- Rapid-cycle Plan-Do-Study-Act methodology was used to test and standardize redesigns.
- No outcome errors occurred during the study period (March-June 2001) and the subsequent 8 months post-implementation.
Conclusions:
- Failure Mode and Effect Analysis (FMEA) proved effective in identifying and mitigating errors in the blood transfusion process.
- The FMEA process was resource-intensive and should be prioritized for critical organizational processes.