A Practical Guide to Failure Mode and Effects Analysis in Health Care: Making the Most of the Team and Its Meetings

Ashley, Laura; Armitage, Gerry; Neary, Maria; Hollingsworth, Gillian

doi:10.1016/s1553-7250(10)36053-3

Cited by 65 publications

(74 citation statements)

References 21 publications

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“…Without guidance and adequate training on what constitute contributory factors, individuals may have a tendency to focus on the more proximal determinants of patient safety incidents 4 5. While more proactive systems exist to explore systems weaknesses in organisations (eg, Failure Modes and Effect Analysis6) these are often resource intensive, and as such difficult to routinely implement 7. There is a clear need to develop a proactive, low-cost system for identifying and learning from systems weaknesses in hospital settings.…”

Section: Introductionmentioning

confidence: 99%

Developing a reliable and valid patient measure of safety in hospitals (PMOS): a validation study

et al. 2013

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Section: Introductionmentioning

confidence: 99%

Developing a reliable and valid patient measure of safety in hospitals (PMOS): a validation study

et al. 2013

Self Cite

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“…In contrast to challenges associated with FMEA as discussed by others [18, 19], this method follows guidelines as proposed elsewhere [9, 20, 21] that are designed to improve the efficiency of the PRA. In this case we divided the method into three phases to more appropriately utilize resources and personnel.…”

Section: Discussionmentioning

confidence: 99%

“…When implementing health information technology (IT) such as CPOE in a complex healthcare environment, it is even more critical to ensure that the PRA method is conducted in an efficient manner. Research on PRA has produced a set of guidelines to use when preparing for the team portion of a PRA [9, 20, 21]. …”

Section: Introductionmentioning

confidence: 99%

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit

Hundt

Adams

Schmid

et al. 2013

International Journal of Medical Informatics

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Purpose To develop, conduct, and evaluate a proactive risk assessment (PRA) of the design and implementation of CPOE in an ICU. Methods We developed a PRA method based on issues identified from documented experience with conventional PRA methods and the constraints of an organization about to implement CPOE in an intensive care unit. The PRA method consists of three phases: planning (three months), team (one five-hour meeting), and evaluation (short- and long-term). Results Sixteen unique relevant vulnerabilities were identified as a result of the PRA team’s efforts. Negative consequences resulting from the vulnerabilities included potential patient safety and quality of care issues, non-compliance with regulatory requirements, increases in cognitive burden on CPOE users, and/or worker inconvenience or distress. Actions taken to address the vulnerabilities included redesign of the technology, process (workflow) redesign, user training, and/or ongoing monitoring. Verbal and written evaluation by the team members indicated that the PRA method was useful and that participants were willing to participate in future PRAs. Long-term evaluation was accomplished by monitoring an ongoing “issues list” of CPOE problems identified by or reported to IT staff. Vulnerabilities identified by the team were either resolved prior to CPOE implementation (n = 7) or shortly thereafter (n = 9). No other issues were identified beside those identified by the team. Conclusions Generally positive results from the various evaluations including a long-term evaluation demonstrate the value of developing an efficient PRA method that meets organizational and contextual requirements and constraints.

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“…Se apreció que en el PA del paciente de COMF intervienen mecanismos estratégicos habitualmente establecidos por el Servicio andaluz de Salud (SAS), procesos claves asociados al tratamiento médico-quirúrgico que requiere el paciente hasta su alta hospitalaria, y procesos de soporte que apoyarán la consecución de los objetivos planteados en el PA del paciente de COMF. Se procedió a la descripción de la Metodología de Análisis Modal de Fallos y Efectos (AMFE) (9,10). Aunque el equipo se estuvo formando a través de la plataforma SPif, fue necesario apostar por la formación continua, en aras de planificar una estrategia interactiva en la adquisición del conocimiento.…”

Section: Mapa De Riesgos De Una Unidad De Gestión Clínica De Cirugía unclassified

Risk map of a Clinical Management Unit for Oral and Maxillofacial Surgery in Granada

López¹,

Martín²,

Páez³

et al. 2017

Actual. Med

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ResumenObjetivos. El objetivo general de este estudio es desarrollar e implementar un mapa de riesgos encaminado a la mejora de la seguridad de los pacientes en la Unidad de Gestión Clínica de Cirugía Oral y Maxilofacial del Complejo Hospitalario Universitario de Granada para minimizar la incidencia de efectos adversos y lograr una mejora de la calidad asistencial. Métodos. Se analizó retrospectivamente la situación actual de la Seguridad del paciente en la Unidad de gestión clí-nica, enfocando la metodología de trabajo a través de un equipo interdisciplinar y elaboración de un cronograma. El trabajo se realizó secuencialmente a través de las siguientes fases: análisis de la situación actual de la seguridad del paciente en la Unidad mediante dos sistemas de análisis: DAFO y PITELO, y elaboración de un flujograma del proceso de atención al paciente empleando el análisis metodológico AMFE; elaboración y consenso del proceso de atención del paciente; identificación de los posibles efectos adversos; cálculo del índice de prioridad de riesgo; elaboración de las Acciones Preventivas para los fallos y causas detectados; creación del mapa de riesgos específico de la unidad. Resultados. El análisis DAFO y PITELO constata como principales debilidades la insuficiente formación de los profesionales sanitarios sobre la seguridad del paciente y la infranotificación de efectos adversos, así como la ausencia de retroalimentación entre la Unidad de registro de efectos adversos y los mismos. Entre sus fortalezas destaca la existencia de líderes implicados en la mejora de la calidad. El catálogo muestra los 33 efectos adversos identificados en la Unidad, clasificando sus fallos y causas, y detallando sus correspondientes medidas preventivas. Conclusiones. La elaboración de un mapa de riesgos permite determinar el circuito del paciente de Cirugía Oral y Maxilofacial, y elaborar un catálogo de efectos adversos con la finalidad de asegurar y mejorar la calidad asistencial. AbstractAims. The main aim of this study is to develop and implement a risk map in order to improve the patient safety strategy of the Oral Surgery Clinical Management Unit in the University Hospital Complex of Granada to minimize the incidence of adverse effects and gaining improvement of healthcare quality. Methods. The current situation of patient safety of the Oral Surgery Clinical Management Unit was analyzed retrospectively, focusing the methodology through an interdisciplinary team and elaborating a schedule. The work was carried out sequentially through the following phases: analysis of the current situation of patient safety in the Unit through the analysis systems SWOT and PITELO, and elaboration of a flow chart of the patient care process using the AMFE methodological analysis; elaboration and consensus of the patient care process; identification of possible adverse effects; calculation of the risk priority index; setting of the preventive actions for the detected failures and causes; and creation of the map of specific risks of the Unit. Results. The SW...

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A Practical Guide to Failure Mode and Effects Analysis in Health Care: Making the Most of the Team and Its Meetings

Cited by 65 publications

References 21 publications

Developing a reliable and valid patient measure of safety in hospitals (PMOS): a validation study

Developing a reliable and valid patient measure of safety in hospitals (PMOS): a validation study

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit

Risk map of a Clinical Management Unit for Oral and Maxillofacial Surgery in Granada

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