Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.

Tosha B. Wetterneck; Kathleen Skibinski; Tanita L. Roberts; Susan M. Kleppin; Mark E. Schroeder; Myra Enloe; Steven S. Rough; Ann Schoofs Hundt; Pascale Carayon

Study

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.

August 23, 2006

Wetterneck TB, Skibinski K, Roberts TL, et al. Am J Health Syst Pharm. 2006;63(16):1528-38.

View more articles from the same authors.

The authors describe their use of failure mode and effects analysis to inform the launch of a smart pump initiative and found that it was useful for identifying potential problems with the implementation.

PubMed citation

Available at

Related Resources From the Same Author(s)

FMEA team performance in health care: a qualitative analysis of team member perceptions.

June 24, 2009

Evaluation of nurse interaction with bar code medication administration technology in the work environment.

March 28, 2007

Human factors systems approach to healthcare quality and patient safety.

August 14, 2013

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

June 13, 2012

ICU nurses' acceptance of electronic health records.

July 13, 2011

Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences.

November 14, 2007

February 8, 2017

SEIPS 3.0: human-centered design of the patient journey for patient safety.

February 19, 2020

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units.

November 6, 2013

Changes in end-user satisfaction with computerized provider order entry over time among nurses and providers in intensive care units.

November 28, 2012

Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

August 17, 2011

Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.

March 15, 2017

A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.

May 31, 2017

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients.

October 3, 2013

Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.

January 8, 2020

Work system design for patient safety: the SEIPS model.

October 12, 2011

Adverse event reporting: harnessing residents to improve patient safety.

November 8, 2017

From tasks to processes: the case for changing health information technology to improve health care.

April 1, 2009

Human factors in patient safety as an innovation.

June 2, 2010

Human factors of complex sociotechnical systems.

June 28, 2006

Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.

May 14, 2008

Care at the point of impact: insights into the second-victim experience.

May 18, 2016

A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety.

March 25, 2015

Contributions of tele-intensive care unit (tele-ICU) technology to quality of care and patient safety.

January 23, 2013

A roadmap to advance patient safety in ambulatory care.

January 20, 2021

The effects of computerized provider order entry implementation on communication in intensive care units.

February 20, 2013

Refocusing the lens: patient safety in ambulatory chronic disease care.

July 1, 2009

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Exploring performance obstacles of intensive care nurses.

November 19, 2008

A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units.

October 12, 2005

Strategies for improving family engagement during family-centered rounds.

May 29, 2013

Human factors and ergonomics as a patient safety practice.

July 31, 2013

Association of communication between hospital-based physicians and primary care providers with patient outcomes.

January 21, 2009

Handovers from the OR to the ICU.

January 23, 2013

Meaningful use's benefits and burdens for US family physicians.

May 30, 2018

Associations between perceived crisis mode work climate and poor information exchange within hospitals.

February 4, 2015

Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life.

April 1, 2009

Parents' perceptions of medical errors.

June 16, 2010

Family-initiated dialogue about medications during family-centered rounds.

February 11, 2015

Ending disruptive behavior: staff nurse recommendations to nurse educators.

September 4, 2013

Information chaos in primary care: implications for physician performance and patient safety.

November 30, 2011

State of science: human factors and ergonomics in healthcare.

September 4, 2013

The SAGES FUSE program: bridging a patient safety gap.

October 22, 2014

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

February 12, 2020

How often are potential patient safety events present on admission?

February 27, 2008

Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors.

September 13, 2017

Surgeons don't know what they don't know about the safe use of energy in surgery.

June 20, 2012

The top patient safety strategies that can be encouraged for adoption now.

March 13, 2013

Effects of technological interventions on the safety of a medication-use system.

January 17, 2007

Some cancer experts see 'overdiagnosis,' question emphasis on early detection.

October 1, 2014

Risk of adverse drug events by patient destination after hospital discharge.

September 21, 2005

Another surgeon's error: must you tell the patient?

October 15, 2014

Challenges and opportunities for improving patient safety through human factors and systems engineering.

December 5, 2018

Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital.

August 19, 2009

Are parents who feel the need to watch over their children's care better patient safety partners?

December 6, 2017

Strategies for developing and recognizing faculty working in quality improvement and patient safety.

June 1, 2016

Using patient safety indicators to estimate the impact of potential adverse events on outcomes.

January 30, 2008

National surveillance of emergency department visits for outpatient adverse drug events.

October 18, 2006

Using computerized virtual cases to explore diagnostic error in practicing physicians.

February 13, 2019

Caring for our own: deploying a systemwide second victim rapid response team.

April 28, 2010

Parent perceptions of children's hospital safety climate.

April 17, 2013

Advancing the science of patient safety.

May 25, 2011

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

June 16, 2010

Fundamental Use of Surgical Energy (FUSE): an essential educational program for operating room safety.

April 5, 2017

An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.

February 23, 2011

A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS).

July 31, 2013

Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach.

August 31, 2016

Self-reported violations during medication administration in two paediatric hospitals.

May 16, 2012

Physician Quality Officer: a new model for engaging physicians in quality improvement.

June 24, 2009

The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use.

February 28, 2007

Evaluating the Patient Safety Indicators: how well do they perform on Veterans Health Administration data?

September 7, 2005

Why it is so hard to talk about overuse in pediatrics and why it matters.

August 30, 2017

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.

September 12, 2018

National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents.

March 5, 2008

On the prospects for a blame-free medical culture.

November 4, 2009

The risks to patient safety from health system expansions.

April 18, 2018

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care.

November 16, 2016

Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning.

December 19, 2012

In situ simulated cardiac arrest exercises to detect system vulnerabilities.

June 10, 2015

Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.

November 21, 2007

Attending physician work hours: ethical considerations and the last doctor standing.

July 29, 2009

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.

April 12, 2023

Rapid response teams seen through the eyes of the nurse.

August 4, 2010

Differences in hospitals' workplace violence incident reporting practices: a mixed methods study.

May 18, 2022

Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients.

March 11, 2020

EHR safety: the way forward to safe and effective systems.

April 2, 2008

Use of a novel, modified fishbone diagram to analyze diagnostic errors.

July 16, 2014

Improving patient safety by repeating (read-back) telephone reports of critical information.

March 6, 2005

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

December 7, 2016

Failure mode and effects analysis to reduce risk of heparin use.

January 29, 2020

Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership.

November 19, 2014

Communicating with patients about medical errors: a review of the literature.

March 6, 2005

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

March 30, 2011

Tracking rates of patient safety indicators over time: lessons from the Veterans Administration.

September 6, 2006

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

March 30, 2011

January 31, 2007

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation.

May 11, 2022

Bringing diagnosis into the quality and safety equations.

October 3, 2012

Promethazine adverse events after implementation of a medication shortage interchange.

April 15, 2005

Related Resources

Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls.

January 25, 2023

Intravenous smart pumps at the point of care: a descriptive, observational study.

October 12, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

The effect of blue-enriched lighting on medical error rate in a university hospital ICU.

January 27, 2021

Algorithmic prediction of failure modes in healthcare.

January 13, 2021

An integrative total worker health framework for keeping workers safe and healthy during the COVID-19 pandemic.

July 1, 2020

Stakeholder perceptions of smart infusion pumps and drug library updates: a multisite, interdisciplinary study.

September 25, 2019

Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting.

September 18, 2019

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

Unintended patient safety risks due to wireless smart infusion pump library update delays.

March 13, 2019

Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

February 13, 2019

Intravenous smart pump drug library compliance: a descriptive study of 44 hospitals.

December 12, 2018

Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety.

July 11, 2018

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

Improving infusion pump safety through usability testing.

May 31, 2017

Understanding models of error and how they apply in clinical practice.

July 20, 2016

Adverse events in robotic surgery: a retrospective study of 14 years of FDA data.

June 8, 2016

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

March 16, 2016

Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts.

March 18, 2015

The mixed blessings of smart infusion devices and health care IT.

October 8, 2014

Application of failure mode effect analysis to improve the care of septic patients admitted through the emergency department.

October 1, 2014

The role of failure mode and effects analysis in health care.

September 24, 2014

Sound the alarm.

June 25, 2014

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis.

May 21, 2014

Augmenting health care failure modes and effects analysis with simulation.

March 5, 2014

Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety.

February 12, 2014

Using good design to eliminate medical errors.

November 20, 2013

The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study.

October 9, 2013

Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model.

October 2, 2013

Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery.

September 25, 2013

See More About The Topic

Quality and Safety Professionals

Safety Scientists

Engineers

Infusion Pumps

Failure Mode Effects Analysis

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site