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Updated: Oct 4, 2025

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
Published on: February 16, 2011
The Healthcare Failure Mode and Effect Analysis as a tool to evaluate care protocols
Alissa Xavier da Costa Furtado Abi1, Elaine Dhemer de Almeida Cruz1, Letícia Pontes1
1Universidade Federal do Paraná. Curitiba, Paraná, Brazil.
Objectives:
to identify, classify, and analyze modes of failure in the medication process.
Methods:
evaluative research that used the Healthcare Failure Mode and Effect Analysis (HFMEA) in a service of bone marrow transplant from June to September 2018, with the participation of 35 health workers.
Results:
207 modes of failure were identified and classified as mistakes in verification (14%), scheduling (25.6%), administration (29%), dilution (16.4%), prescription (2.4%), and identification (12.6%). The analysis of risk showed a moderate (51.7%) and high (30.9%) need of intervention, leading to the creation of an internal quality assurance group and of continued education activities.
Conclusions:
the Healthcare Failure Mode and Effect Analysis showed itself to be a tool to actively identify, classify, and analyze failures in the process of medication, contributing for the proposal of actions aimed at patient safety.
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