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To err is human: improving patient safety through failure mode and effect analysis.

Sherry Woodhouse1, Brenda Burney, Kathleen Coste

  • 1Cleveland Clinic Florida, Weston, Florida, USA.

Clinical Leadership & Management Review : the Journal of CLMA
|February 19, 2004
PubMed
Summary

Patient care errors in labs are often blamed on individuals. Failure Mode and Effect Analysis (FMEA) offers a proactive, systematic approach to prevent errors by anticipating failures and improving patient safety.

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Area of Science:

  • Medical error analysis
  • Laboratory quality management
  • Patient safety science

Background:

  • Laboratory errors are a significant concern in patient care.
  • Traditional error prevention focuses on individual performance, assuming technologists perform flawlessly with training.
  • Existing laboratory processes often assume no failures will occur.

Purpose of the Study:

  • To introduce Failure Mode and Effect Analysis (FMEA) as a novel method for laboratory error prevention.
  • To highlight the importance of proactive error identification in enhancing patient safety.
  • To advocate for a shift from reactive to proactive error analysis in healthcare settings.

Main Methods:

  • Failure Mode and Effect Analysis (FMEA) is presented as a systematic, multidisciplinary approach.

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  • FMEA operates on the principle that failures are inevitable and often beyond individual control.
  • The methodology involves anticipating potential failures and their effects to implement preventive measures.

    • Main Results:

    • FMEA provides a proactive framework for identifying potential failure points in laboratory processes.
    • This systematic approach moves beyond blaming individual errors to understanding systemic weaknesses.
    • Implementing FMEA can lead to improved laboratory processes and enhanced patient safety.

    Conclusions:

    • Failure Mode and Effect Analysis (FMEA) is a valuable tool for proactive error prevention in clinical laboratories.
    • Adopting FMEA can significantly contribute to improving patient safety by addressing systemic vulnerabilities.
    • Healthcare organizations, including those accredited by the Joint Commission, should consider FMEA for process improvement.