Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards

Abstract

BackgroundIntravenous potassium chloride (IV KCl) solutions are widely used in hospitals for treatment of hypokalemia. As ampoules of concentrated KCL must be diluted before use, critical incidents have been associated with its preparation and administration. Currently, we have introduced ready-to-use diluted KCl infusion solutions to minimize the use of high-alert concentrated KCl. Since this process may be associated with considerable risks, we embraced a proactive hazard analysis as a tool to implement a change in high-alert drug usage in a hospital setting.MethodsFailure mode and effect analysis (FMEA) is a systematic tool to analyze and identify risks in system operations. We used FMEA to examine the hazards associated with the implementation of the ready-to-use solutions. A multidisciplinary team analyzed the risks by identifying failure modes, conducting a hazard analysis and calculating the criticality index (CI) for each failure mode. A 1-day survey was performed as an evaluation step after a trial run period of approximately 4 months.ResultsSix major possible risks were identified. The most severe risks were prioritized and specific recommendations were formulated. Out of 28 patients receiving IV KCl on the day of the survey, 22 received the ready-to-use solutions and 6 received the concentrated solutions as instructed. Only 1 patient received inappropriate ready-to-use KCl.ConclusionsUsing the FMEA tool in our study has proven once again that by creating a gradient of severity of potential vulnerable elements, we are able to proactively promote safer and more efficient processes in health care systems. This article presents a utilization of this method for implementing a change in hospital policy regarding the routine use of IV KCl.

Targeting specimen misprocessing safety events with failure modes and effects analysis

“…Health care centers are becoming ever more reliant on effective processes to compensate for a lack of resources and increasingly complex information technology systems. Conducting FMEA allows users to identify which failures are most in need of the resources available to best promote a safer process . What makes FMEA unique among quality improvement tools is that each safety failure can be fairly compared, its risk can be assessed, and a score can be assigned.…”

Peran Metode Failure Mode and Effect Analysis (FMEA) terhadap Mutu Pelayanan Rumah Sakit: Systematik Review

“…Sedangkan Najafpour et al (2017) melakukan evaluasi risiko proses transfusi darah dalam pengajaran rumah sakit umum dengan menggunakan metode FMEA. Penelitian lainnya yaitu Ofek et al (2016) menganalisis risiko terkait dengan pengenalan perubahan kebijakan rumah sakit terkait penggunaan solusi kalium klorida intravena untuk mengurangi bahaya pasien. Aranaz-Andres et al 2017melakukan FMEA untuk administrasi oral obat cair oleh jarum suntik oral.…”

“…Metode FMEA dapat digunakan untuk meningkatkan keamanan, keandalan, evaluasi risiko, kendali mutu dan proses transfusi darah (Zhila et al, 2017). Artikel keempat belas yang dilakukan oleh Ofek et al, (2016) tentang penggunaan metode FMEA pada proses pelayanan dalam pemberian KCL di rumah sakit. Penggunaan FMEA mampu untuk meningkatkan proaktif keamanan dan proses yang efesien di sistem pelayanan kesehatan.…”

Prevention is better: the case of the underutilized failure mode effect analysis in patient safety

“…In a recent IJHPR article, Fanny Ofek et al report on the use of prospective hazard analysis to implement policy change for intravenous potassium chloride (IV KCl) administration. They review the impetus for change, criteria for selection of the failure mode and effect analysis (FMEA) methodology, and the patient safety enhancements that resulted from successful utilization of the methodology [ 2 ]. The authors discussed the motives for changing the policy and administration methods for IV KCl, including to reduce the risk of accidental overdose of high-alert medications.…”