Prospective risk analysis of health care processes: A systematic evaluation of the use of HFMEA™ in Dutch health care

Abstract

The aim of this study was to evaluate the use of Healthcare Failure Mode and Effect Analysis (HFMEA) in Dutch health care by means of user feedback. Thirteen HFMEA analyses of various health care processes were successfully concluded and on average took 69 person-hours (excluding reporting). These results show that HFMEA can successfully be applied in Dutch health care. However, the user feedback also uncovered several perceived drawbacks, such as the fact that HFMEA is very time-consuming and that, particularly, the risk assessment part of HFMEA is difficult to carry out. Moreover, a lack of guidance with regard to the identification of failure mode causes and effective actions might influence the quality of the outcomes of an HFMEA analysis. Several suggestions are put forward to improve the perceived utility and acceptance of HFMEA. Nevertheless, future research is necessary to evaluate the actual effects of these recommendations. Error modelling and risk analysis, and their contribution to explaining human performance in socio-technical systems, traditionally belong to the field of ergonomics. The user feedback on HFMEA and the suggestions that are put forward may also be useful for (H)FMEA and hazard analysis and critical control point applications in sectors other than health care.

Central or local incident reporting? A comparative study in Dutch GP out-of-hours services

“…Moreover, the CIRP started focusing on trends and recurring problems instead of on incident reports only. For instance, a prospective risk analysis 23 of the process of assigning home visits by the CIRP was triggered by several incident reports from different OHSs. In addition, a root cause analysis was performed in response to six incidents with tissue glue for small cut wounds, reported in the last 2 years from four OHSs.…”

Temporal Series Analysis on Avoidable Mortality for the Assessment of an Intervention Program in a Hospital

“…Rather, they are generally a combination of multiple errors that may be related to deficiencies of the system or be directly dependent on the professional. 19 The present study developed a strategy which is garnering excellent results in Holland and the United States, [20][21][22] motivating and providing incentives to healthcare personnel to improve their professional activity and decrease mortality due to HI pathologies.…”

NCS Report 22: Code of practice for the quality assurance and control for intensity modulated radiotherapy

“…It was first developed at the VA National Center for Patient Safety in America by DeRosier et al In 2006, a ZonMW project resulted in a Dutch translation of HFMEA that was adopted to the Dutch healthcare situation (137,123,138). Not only the risk assessment itself is described, the entire process of risk management is outlined.…”