Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions

Area of Science:

• Neurosurgery
• Critical Care Medicine
• Systems Engineering
• Patient Safety

Background:

• Inter-hospital transfers for neurocritical care, including stroke and intracerebral hemorrhage, are common but prone to errors due to multiple handoffs.
• The process involves various providers across different institutions, increasing vulnerability to communication failures and patient safety risks.

Purpose of the Study:

• To present Failure Mode and Effect Analysis (FMEA) as a systems engineering methodology to enhance neurocritical care transitions.
• To describe the implementation of FMEA to improve the safety of inter-hospital transfers for patients with intracerebral and subarachnoid hemorrhage.

Main Methods:

• Assembled a multi-disciplinary team to map the transfer process and identify potential failure modes.
• Conducted risk analysis to prioritize failure modes impacting patient safety.
• Developed and implemented interventions to redesign the process, establishing evaluation methods for continuous improvement.

Main Results:

• Significant reduction in emergency department (ED) throughput, with ED length of stay decreasing from 300 to 149 minutes (p < .01).
• Substantial improvement in inter-disciplinary communication, with pre-intervention discussion rates at 10% increasing to 64% post-intervention.

Conclusions:

• The FMEA approach facilitated meaningful and sustained process changes for neurocritical care patients.
• FMEA is a powerful tool for quality improvement, enhancing communication, resource utilization, and patient safety in healthcare programs.