Anticipation of Error for High Reliability: The Failure Mode Effects Analysis

Tool: Failure mode effects analysis (FMEA) is a systematic review of a process that identifies the potential failures, the causes of those failures and the significance of the failure to our patients or systems. The failure modes are prioritized based on the likelihood of occurrence and the severity of the harm.Problem:COVID-19 led to our ICU over capacity with inability to transfer very sick ICU patients due to the lack of ICU beds in our state. We needed to assess the risk of providing ICU care in different areas and ways and with other staff members providing care.

Tool Selection: The Failure Mode Analysis Effects (FMEA) process is perfect tool to anticipate and mitigate errors before they cause harm. The FMEA is best used to quickly assess for failures in new processes before they are implemented in order to mitigate harm before it reaches a patient.

Usage: The FMEA was used within an interdisciplinary group to assess the risks in boarding ICU patients in the Emergency Department and on Acute Care floors. The group mapped processes, analyzed failures and causes, then prioritized the highest risk failures and outlined action plans for mitigation.

Results: The modified FMEA process identified several failure modes that could be mitigated that we would not have found had we not done the FMEA. We implemented a program of ICU RN partnership for support of ICU patients out of the ICU environment that was successful in preventing adverse outcomes.

Director of Quality & Patient Safety Officer
Director of Quality & Patient Safety Officer – Centura Health

Speaker Type: 60 Minute Session On-Demand, HQ Best Practice Tools On-Demand

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