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Approach to Improving Safety
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- Failure Mode Effects Analysis
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Journal Article > Study
Opportunities for performance improvement in relation to medication administration during pediatric stabilization.
Morgan N, Luo X, Fortner C, Frush K. Qual Saf Health Care. 2006;15:179-183.
The investigators observed simulated scenarios to evaluate nurses' clinical performance during medication administration. They found that improvements could be made in several areas, including the use of read-backs and medication preparation, measurement, and selection.
Special or Theme Issue
Special Issue: Patient Safety.
Ergonomics. 2006;49:439-630.
The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.
Journal Article > Study
Failure mode and effects analysis: a comparison of two common risk prioritisation methods.
McElroy LM, Khorzad R, Nannicelli AP, Brown AR, Ladner DP, Holl JL. BMJ Qual Saf. 2016;25:329-336.
Failure mode and effect analysis (FMEA) is a human factors engineering method used to examine a process in health care to identify potential safety risks. Comparing a traditional resource-intensive FMEA with a simplified version, this analysis found that the simplified method identified risks accurately. These results should encourage more widespread use of this more feasible version of FMEA.
Journal Article > Study
Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.
De Giorgi I, Fonzo-Christe C, Cingria L, et al. Int J Qual Health Care. 2010;22:170-178.
This study used failure modes and effects analysis to identify the major hazards associated with intravenous medication administration and cost-effective approaches for improving safety.
Journal Article > Study
Is failure mode and effect analysis reliable?
Shebl NA, Franklin BD, Barber N. J Patient Saf. 2009;5:86-94.
Failure mode and effect analysis (FMEA) is a widely used tool for hazard analysis. However, in this study, independent FMEA of the same process conducted by separate groups failed to reach similar conclusions regarding potential failures and their severity.
Journal Article > Study
A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.
Rodriguez-Paz JM, Mark LJ, Herzer KR, et al. Anesth Analg. 2009;108:202-210.
This study describes the use of a systematic process, similar to a failure mode effects analysis, that anticipates potential safety issues before introducing a new intraoperative radiation therapy. The authors suggest their process can be applied to the introduction of any new technologies, treatments, or procedures.
Book/Report
To Err Is Human—But Don't Expect to Get Paid For It.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Journal Article > Study
Teamwork and quality during neonatal care in the delivery room.
Thomas EJ, Sexton JB, Lasky RE, Helmreich RL, Crandell DS, Tyson J. J Perinatol. 2006;26:163-169.
The researchers videotaped neonatal resuscitation teams over 1 year to observe their interaction behaviors and compliance with guidelines. They found correlations between team behaviors and compliance with guidelines and overall quality of care.
Journal Article > Study
Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue.
Seago JA, Williamson A, Atwood C. J Nurs Adm. 2006;36:13-21.
The investigators analyzed the effect of nurse staffing on outcomes over a 4-year period. They found that an increase in nursing hours and staffing mix resulted in higher levels of patient satisfaction.