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- Communication Improvement 3
- Culture of Safety
- Education and Training 2
- Error Reporting and Analysis
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Teamwork 1
- Clinical Information Systems 1
Search results for "Failure Mode Effects Analysis"
- Culture of Safety
- Failure Mode Effects Analysis
Journal Article > Study
White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-380.
Medication reconciliation is necessary to reduce preventable medication errors, but despite much research, no consensus exists on how the process should be performed in either the inpatient or outpatient setting. This study, conducted at a children's hospital, demonstrates how accurate medication reconciliation can be achieved through establishing a culture of safety and rigorously applying quality improvement principles. Although the hospital had an existing electronic health record and computerized provider order entry system, a reliable medication reconciliation process was not achieved until existing processes were thoroughly analyzed, failure modes were determined, and rapid cycle tests of change were conducted. As medication reconciliation will be reinstated as a National Patient Safety Goal in July 2011, this article provides a useful blueprint for organizations tackling this difficult problem.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.
Journal Article > Commentary
Sheridan-Leos N, Schulmeister L, Hartranft S. Clin J Oncol Nurs. 2006;10:393-398.
The authors present failure mode and effect analysis (FMEA) as a tool for understanding errors in the chemotherapy administration process.
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.
Cases & Commentaries
- Web M&M
Hedy Cohen, RN, BSN, MS; February-March 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
Special or Theme Issue
Health Serv Res. 2006;41:1535-1720.