Targeting specimen misprocessing safety events with failure modes and effects analysis

Stravitz, Pamela E.; Cibas, Edmund S.; Heher, Yael K.

doi:10.1002/cncy.22096

Cited by 3 publications

(1 citation statement)

References 15 publications

(11 reference statements)

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“…FMEA also has some barriers such as limits of human error analysis (traditional FMEA uses potential equipment/system failures) and missing interactions between faults and external influences. The reproducibility and generalizability of FMEA in clinical laboratory approaches are factors of concern but since this method is based on hypothetical possibilities uncertainty is still likely to remain [27]. Previous study showed that using FMEA is more time-consuming than other hazard analysis that identifies failure modes but the improvement potentially obtainable by FMEA in a clinical laboratory is high, and this fact should suggest further experiences in this field.…”

Section: Fmea Benefits and Barriersmentioning

confidence: 99%

Control of Clinical Laboratory Errors by FMEA Model

Sabati¹,

Mohsenzadeh²,

Khelghati³

2022

Contemporary Topics in Patient Safety - Volume 1

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Patient safety is an aim for clinical applications and is a fundamental principle of healthcare and quality management. The main global health organizations have incorporated patient safety in their review of work practices. The data provided by the medical laboratories have a direct impact on patient safety and a fault in any of processes such as strategic, operational and support, could affect it. To provide appreciate and reliable data to the physicians, it is important to emphasize the need to design risk management plan in the laboratory. Failure Mode and Effect Analysis (FMEA) is an efficient technique for error detection and reduction. Technical Committee of the International Organization for Standardization (ISO) licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. FMEA model helps to identify quality failures, their effects and risks with their reduction/elimination, which depends on severity, probability and detection. Applying FMEA in clinical approaches can lead to a significant reduction of the risk priority number (RPN).

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Section: Fmea Benefits and Barriersmentioning

confidence: 99%

Control of Clinical Laboratory Errors by FMEA Model

Sabati¹,

Mohsenzadeh²,

Khelghati³

2022

Contemporary Topics in Patient Safety - Volume 1

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Research on Product Failure Prediction Based on TRIZ Theory

Zhang

Yue

Jiang

et al. 2021

IOP Conf. Ser.: Mater. Sci. Eng.

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Failure prediction at the product design stage can improve product quality and reduce input costs. Many existing failure analysis methods were susceptible to staff brainstorming during failure excavation, resulting in distortion of results. To overcome the shortcomings of the existing failure analysis methods, according to the interaction characteristics of substance attributes from the functional perspective of TRIZ theory, and drawing on the analysis process of anticipatory failure determination (AFD) method, a general model which was suitable for mechanical products and can effectively determine the potential failure modes and causes of components was established. The feasibility of the model was verified by the example of the fixed-bed gas-gas heat exchanger.

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Combining failure modes and effects analysis and cause–effect analysis: a novel method of risk analysis to reduce anaphylaxis due to contrast media

Koike¹,

Yamakami²,

Miyashita³

et al. 2022

International Journal for Quality in Health Care

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Background Contrast media agents are essential for computed tomography-based diagnoses. However, they can cause fatal adverse effects such as anaphylaxis in patients. Although it is rare, the chances of anaphylaxis increase with the number of examinations. Thus, we aimed to design a quality-improvement initiative to reduce patient risk to these agents. Methods We analysed computed tomography processes using contrast iodine in a tertiary-care academic hospital that performs approximately 14,000 computed tomography scans per year in Japan. We applied a combination of failure modes and effects analysis and cause–effect analysis to reduce the risk of patients developing allergic reactions to iodine-based contrast agents during computed tomography imaging. Results Our multidisciplinary team comprising seven professionals analysed the data and designed a 56-process flowchart of computed tomography imaging with iodine. We obtained 177 failure modes, of which 15 had a risk-probability number higher than 100. We identified the two riskiest processes and developed cause-and-effect diagrams for both: one was related to exchange of information between the radiation and hospital information system regarding the patient’s allergy, the other was due to education and structural deficiencies in observation following the exam. Conclusion The combined method of failure mode effect analysis and cause-and-effect analysis reveals high-risk processes and suggests measures to reduce these risks. Failure modes and effects analysis is not well-known in healthcare but has significant potential for improving patient safety. Our findings emphasise the importance of adopting new techniques to reduce patient risk and carry out best practices in radiology.

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Targeting specimen misprocessing safety events with failure modes and effects analysis

Cited by 3 publications

References 15 publications

Control of Clinical Laboratory Errors by FMEA Model

Control of Clinical Laboratory Errors by FMEA Model

Research on Product Failure Prediction Based on TRIZ Theory

Combining failure modes and effects analysis and cause–effect analysis: a novel method of risk analysis to reduce anaphylaxis due to contrast media

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