Using ISMP Canada's Framework for Failure Mode and Effects Analysis: A Tale of Two FMEAs

Nickerson, Tim; Jenkins, Margie; Greenall, Julie

doi:10.12927/hcq.2008.19648

Cited by 24 publications

(28 citation statements)

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“…Several studies have recognized the importance that HFMEA has when it comes to identifying failure modes (FMs), its causes and consequences in a variety of health-care processes, such as distribution and the administration of medicines, parenteral nutrition, and chemotherapy (31)(32)(33)(34)(35)(36)(37)(38)(39). As recently demonstrated in a study by Castro Vida et al (40), the HFMEA has been conducted in all processes and sub-processes in hospital pharmacies except for medicine-shortage management (40).…”

Section: Introductionmentioning

confidence: 99%

Risks in Antibiotic Substitution Following Medicine Shortage: A Health-Care Failure Mode and Effect Analysis of Six European Hospitals

et al. 2020

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Introduction: Medicine shortages result in great risk for the continuity of patient care especially for antimicrobial treatment, potentially enhancing resistance rates and having a higher economic impact. This study aims to identify, describe, assess, and assign risk priority levels to potential failures following substitution of antimicrobial treatment due to shortages among European hospitals. Furthermore, the study investigated the impact of corrective actions on risk reduction so as to provide guidance and improve future patient care. Methods: Health-care failure mode and effect analysis (HFMEA) was applied to hospitals in Austria (H-AT), Belgium (H-BE), Croatia (H-CR), Greece (H-GR), Spain (H-SP), and Serbia (H-SR). Multidisciplinary teams identified processes, failure modes, causes, and corrective actions related to antibiotic substitution following medicine shortages. Characteristics of study hospitals as well as severity, probability, and hazard scores (HSs) of failure modes/causes were analyzed using Microsoft Office Excel 2010 and IBM SPSS Statistics® via descriptive and inferential statistics. Results: Through HFMEA, 74 failure modes were identified, with 53 of these scoring 8 or above on the basis of assigned severity and probability for a failure. Severity of failure modes differed before and after corrective actions in H-CR, H-GR, and H-SR (p < 0.005). Their probability differed in all study hospitals (p < 0.005) when compared before and after corrective actions aimed to be implemented. The highest number of failure-mode causes was detected in H-CR (46) and the lowest in H-SP (16). Corrective actions can address failure modes and lower HSs; therein, all teams proposed the following: structuring communication among stakeholders, introducing electronic prescribing, strengthening Miljković et al. HFMEA of European Medicine Shortages pharmacists' involvement, and increasing effectiveness of the ward stock assessment. These proposed actions led to HS reductions up to 83%. Conclusion: There is a lack of structure in addressing risks associated with antibiotic substitution following shortages. Furthermore, lack of communication, data scarcity on availability of antibiotics, non-supportive information technology (IT) systems, and lack of internal substitution protocols hinder quick assessment of alternatives addressing patient needs. Nevertheless, the study shows that health-care professionals manage to secure optimal antimicrobial treatment for patients using available IT and human resources.

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Section: Introductionmentioning

confidence: 99%

Risks in Antibiotic Substitution Following Medicine Shortage: A Health-Care Failure Mode and Effect Analysis of Six European Hospitals

et al. 2020

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“…These have been applied to different healthcare areas such as paediatric parenteral nutrition,21 chemotherapy in adult patients22 and especially to paediatric patients,23–25 as well as to different stages of the use of medication such as drug order transcription,26 distribution27 and administration 28. They have also been considered excellent tools for the evaluation of the safe implementation of ITs such as CPOE29 and semi-automated dispensing robots 30…”

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confidence: 99%

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients

et al. 2012

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“…Proactive risk assessment tools have proven to be useful in evaluating the safety of various medication administration processes by forecasting potential failures, revealing process vulnerabilities, and applying control measures before harm occurs (Adachi & Lodolce, 2005;Burgmeier, 2002;Nickerson et al, 2008). Healthcare Failure Mode and Effect Analysis (HFMEA) was chosen to be the risk assessment tool used in this study.…”

Section: Failure Mode and Effect Analysis In Healthcarementioning

confidence: 99%

A Healthcare Failure Mode and Effect Analysis on the Safety of Secondary Infusions

Yue

Trbovich

Easty

2012

Proceedings of the Human Factors and Ergonomics Society Annual

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Secondary infusions are a common and convenient method to administer intermittent infusions unattended through a single IV access using infusion pump technology. Previous studies have indicated that clinicians have a high frequency of committing operation errors while administering secondary infusions, which can cause patient harm. The purpose of this study was to evaluate the safety of secondary infusion practice by identifying and analyzing potential failure modes when delivering secondary infusions on five different smart infusion pumps.Healthcare Failure Mode and Effect Analysis (HFMEA) was used to prioritize potential failure modes that are considered high-risk for each pump. Results showed that four of the five pumps were not able to mitigate physical set-up errors. As well, each pump contributed differently to programming errors due to difference in interface design. Recommendations from this study focused on outlining desired infusion pump features and mitigation strategies to help alleviate high-risk secondary infusion failure modes.iii Acknowledgments I would like to take this opportunity to extend my appreciation to a number of people, more than can be named here, for their support and assistance over the course of this research project.

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Using ISMP Canada's Framework for Failure Mode and Effects Analysis: A Tale of Two FMEAs

Cited by 24 publications

References 1 publication

Risks in Antibiotic Substitution Following Medicine Shortage: A Health-Care Failure Mode and Effect Analysis of Six European Hospitals

Risks in Antibiotic Substitution Following Medicine Shortage: A Health-Care Failure Mode and Effect Analysis of Six European Hospitals

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients

A Healthcare Failure Mode and Effect Analysis on the Safety of Secondary Infusions

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