Failure mode and effects analysis as a performance improvement tool in trauma.

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Clinical Risk Management

Background:

• Performance improvement in trauma care often targets hospital processes.
• Failure Mode Effects Analysis (FMEA) is a proactive risk assessment tool.
• FMEA identifies potential failures before adverse events occur, unlike Root Cause Analysis.

Purpose of the Study:

• To demonstrate the utility of FMEA as a performance improvement tool.
• To analyze a near-miss event in inpatient dialysis for a trauma patient.
• To identify and mitigate risks in the dialysis care delivery process.

Main Methods:

• A near-miss event involving inadvertent heparin administration during dialysis was reviewed.
• Failure Mode Effects Analysis (FMEA) was initiated by the trauma service PI committee.
• The FMEA involved multidisciplinary teams, including physicians, nurses, and allied health professionals, with process observations and interviews.

Main Results:

• Observations revealed inconsistent nursing involvement, lack of formal patient hand-off reports, and inadequate review of dialysis orders.
• Key risk areas identified included inconsistent communication for nephrology consults, informal scheduling, insufficient RN involvement, and potential scope of practice exceedance by technicians.
• Recommendations included enhanced RN education, formal reporting processes, RN supervision, standardized forms, technician scope of practice education, and improved scheduling notification.

Conclusions:

• Near-miss events are crucial opportunities for healthcare improvement.
• FMEA effectively identified systemic risks in inpatient dialysis processes for trauma patients.
• Proactive implementation of FMEA recommendations can enhance patient safety and healthcare delivery.