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Search results for "Hospitals"

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Journal Article > Review

A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy.

Giardina M, Cantone MC, Tomarchio E, Veronese I. Health Phys. 2016;111:317-326.

Health care failure mode and effect analysis (HFMEA) was developed by the Veterans Affairs health system to prospectively identify risks in an organization, analyze the ways in which processes can fail, and take corrective action before failures have occurred. This review discusses how HFMEA can be used in radiotherapy to uncover risks and suggests limitations in the technique that must be addressed.

Journal Article > Commentary

Use of failure mode and effects analysis to improve emergency department handoff processes.

Sorrentino P. Clin Nurse Spec. 2016;30:28-37.

Poor communication during handoffs can hinder health care safety. This commentary describes a project that used failure mode and effects analysis to identify weaknesses in emergency department handoff processes and led to the development of a standardized communication protocol and clarified roles for clinical nurse specialists.

Journal Article > Study

Where are my instruments? Hazards in delivery of surgical instruments.

Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Surg Endosc. 2016;30:2728-2735.

Insufficient instrument availability in the operating room can delay surgery completion and increase risks. This study used failure mode and effect analysis to characterize instrument delivery to operating rooms at two hospitals. Investigators identified multiple vulnerabilities in delivery processes and recommend enhanced information technology support to optimize instrument availability.

Journal Article > Study

Operating room to intensive care unit handoffs and the risks of patient harm.

McElroy LM, Collins KM, Koller FL, et al. Surgery. 2015;158:588-594.

This research group performed a failure mode and effect analysis to study handoffs between the operating room and the intensive care unit for liver transplant patients at a large academic medical center. The authors identified 81 process failures and outlined recommendations to mitigate many of these risks.

Journal Article > Study

High rate of implementation of proposed actions for improvement with the Healthcare Failure Mode Effect Analysis method: evaluation of 117 analyses.

Öhrn A, Ericsson C, Andersson C, Elfström J. J Patient Saf. 2015 Feb 24; [Epub ahead of print].

Failure mode effect analysis is a widely used method of prospectively detecting safety hazards, but evidence of its effectiveness is lacking. This study of 117 FMEAs from 3 hospitals in Sweden found that the recommended safety interventions were implemented in more than three-quarters of cases within a few years.

Journal Article > Study

Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge.

Kaestli LZ, Cingria L, Fonzo-Christe C, Bonnabry P. Int J Clin Pharm. 2014;36:953-962.

Researchers performed prospective risk assessment using failure mode and effects analysis for medication errors following hospital discharge. This method identified more errors than traditional incident reporting, as expected given the known under-reporting in all voluntary safety reporting mechanisms studied.

Journal Article > Study

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

Alamry A, Al Owais SM, Marini AM, Al-Dorzi H, Alsolamy S, Arabi Y. J Patient Saf. 2017;13:76-81.

A multidisciplinary team employed failure mode and effect analysis methodology to detect potential problems in the process of treating patients with sepsis at a large academic medical center in Saudi Arabia. The authors identified a set of corrective actions that they intend to implement to improve patient care.

Journal Article > Study

Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients.

Johnston M, Arora S, Anderson O, King D, Behar N, Darzi A. Ann Surg. 2015;261:831-838.

In most training settings, the first physician point-of-contact for a patient with clinical deterioration is a junior doctor who must evaluate the situation and decide whether to alert a supervising physician—a process termed escalation of care. Delays in this process can lead to critical failure-to-rescue events, which may result in preventable deaths. This study used ethnographic observations, a risk assessment survey, and a formal health care failure mode and effect and analysis to examine the escalation of care process on surgical wards at three London hospitals. The investigation uncovered 18 hazardous failures, with multiple underlying root causes, including outdated communication technology, insufficient staffing, and challenges related to hierarchy. An extensive list of recommendations to improve these processes is included. A prior AHRQ WebM&M commentary discussed some of the pitfalls of hierarchy and the "surgical personality."

Journal Article > Study

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

Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Int J Technol Assess Health Care. 2014;30:210-217.

This study applied failure mode and effect analysis (FMEA) to identify possible risks associated with smart infusion pumps. The investigators used the results to develop training, enhance medication information, and reduce alert fatigue by distinguishing dose programming errors from pump misuse alarms. These findings demonstrate the effectiveness of utilizing a systems approach to address safety issues.

Journal Article > Study

Augmenting health care failure modes and effects analysis with simulation.

Nielsen DS, Dieckmann P, Mohr M, Mitchell AU, Østergaard D. Simul Healthc. 2014;9:48-55.

Failure mode and effect analysis (FMEA) is a widely used tool for identifying latent safety hazards. Traditional FMEA relies on brainstorming among team members to detect failure modes (the ways in which a clinical process might fail). This study found that direct observation of a simulated clinical process improved the FMEA by facilitating identification of different types and a greater number of failure modes.

Cases & Commentaries

Multifactorial Medication Mishap

  • Spotlight Case
  • Web M&M

Annie Yang, PharmD, BCPS; February 2014

Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.

Journal Article > Study

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

Kerckhoffs MC, van der Sluijs AF, Binnekade JM, Dongelmans DA. J Patient Saf. 2013;9:154-159.

Conceptually analogous to failure mode and effect analysis, the Bow-Tie method is used to prospectively detect safety hazards. In this study, the Bow-Tie method was used to identify latent safety hazards in intrahospital transport, risk factors for unintentional extubation, and contributors to poor interdisciplinary communication.

Journal Article > Study

Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections.

Chandonnet CJ, Kahlon PS, Rachh P, et al. Pediatrics. 2013;131:e1961-e1969.

Successful application of a failure mode and effect analysis approach resulted in a marked reduction in the incidence of central line–associated bloodstream infections in a neonatal intensive care unit.

Journal Article > Study

Development and content validation of a surgical safety checklist for operating theatres that use robotic technology.

Ahmed K, Khan N, Khan MS, Dasgupta P. BJU Int. 2013;111:1161-1174.

This study describes how failure mode and effect analysis was used to identify potential safety hazards in robotic surgery.

Journal Article > Study

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.

Lago P, Bizzarri G, Scalzotto F, et al. BMJ Open. 2012;2:e001249.

Failure mode and effect analysis identified calculation errors as a major source of medication errors at a pediatric hospital and helped prioritize approaches to revising the drug administration process.

Journal Article > Study

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

Vélez-Díaz-Pallarés M, Delgado-Silveira E, Carretero-Accame ME, Bermejo-Vicedo T. BMJ Qual Saf. 2013;22:42-52.

In this study, failure mode and effect analysis—a prospective risk assessment tool—successfully identified actions that led to reductions in medication errors at a Spanish university hospital.

Journal Article > Review

'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care—a review of the literature.

Kullberg A, Larsen J, Sharp L. Eur J Oncol Nurs. 2013;17:228-235.

Cancer patients undergoing chemotherapy may be particularly vulnerable to medical errors, as their care often requires use of high-risk medications and must be closely coordinated between multiple physicians. This thematic review focused on methods to improve safety for chemotherapy patients and found evidence that computerized provider order entry could reduce medication errors. However, the authors did not find enough evidence to recommend other interventions that have been proposed, such as patient engagement or teamwork training for patients and families. An AHRQ WebM&M commentary discusses how one institution responded to a serious chemotherapy error.

Journal Article > Study

Failure mode and effects analysis outputs: are they valid?

Shebl NA, Franklin BD, Barber N. BMC Health Serv Res. 2012;12:150.

This study casts doubt on the validity and reliability of failure mode and effect analysis, a commonly used tool to prospectively identify safety hazards.

Journal Article > Study

A systematic proactive risk assessment of hazards in surgical wards: a quantitative study.

Anderson O, Brodie A, Vincent CA, Hanna GB. Ann Surg. 2012;255:1086-1092.

This study reports on a failure mode and effect analysis used to detect and prioritize potential patient safety threats for surgical patients. Patients were directly involved in determining the severity of each potential hazard, providing a novel example of how patients may be engaged in safety efforts.

Journal Article > Study

The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication administration process on the floor.

Nguyen C, Côté J, Lebel D, et al. J Eval Clin Pract. 2013;19:192-199.

This study reports on a multidisciplinary failure mode and effect analysis of nursing medication administration.

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