Narrow Results Clear All
- Culture of Safety 1
- Error Reporting and Analysis
- Human Factors Engineering 2
- Quality Improvement Strategies 1
- Technologic Approaches 1
Search results for ""
Tools/Toolkit > Government Resource
VA National Center for Patient Safety.
These materials provide an introduction to the purpose of healthcare failure mode and effect analysis (HFMEA), the steps of the HFMEA process, and how to apply the technique to address the Joint Commission proactive risk assessment standard.
Journal Article > Study
Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.
DeRosier J, Stalhandske E, Bagian JP, Nudell T. Jt Comm J Qual Improv. 2002;28:248-267, 209.
The authors describe their adaptation of failure mode and effects analysis, a prospective risk assessment tool originally developed in the manufacturing industry, to processes in health care. Their system, Health Care Failure Mode Effects Analysis (HFMEA), is documented in detail, including a complete illustrated example. The system includes tools to prospectively identify process risks in an organization, analyze the ways in which the process can fail, prioritize those failure modes, and take corrective action before failures have occurred. The authors describe the initial deployment of HFMEA in the Veterans Administration health care facilities.
Journal Article > Commentary
Case study: identifying potential problems at the human/technical interface in complex clinical systems.
Caudill-Slosberg M, Weeks WB. Am J Med Qual. 2005;20:353-357.
The authors present a case study to illustrate system vulnerabilities related to computerized physician order entry (CPOE) use.
Web Resource > Course Material/Curriculum
Ann Arbor, MI: National Center for Patient Safety.
This curriculum introduces basic patient safety concepts and provides materials to support students, instructors, and faculty educators.