Failure Mode and Effects Analysis (FMEA) of the Trauma Patient Registration Process

2.50
Hdl Handle:
http://hdl.handle.net/10755/162651
Type:
Presentation
Title:
Failure Mode and Effects Analysis (FMEA) of the Trauma Patient Registration Process
Abstract:
Failure Mode and Effects Analysis (FMEA) of the Trauma Patient Registration Process
Conference Sponsor:Emergency Nurses Association
Conference Year:2007
Author:Day, Suzanne, RN, BSN, MA
P.I. Institution Name:LDS Hospital
Title:Trauma Program Manager
Contact Address:Eighth Ave. and C Street, Salt Lake City, UT, 84092, USA
Contact Telephone:(801) 408-3631
Co-Authors:Jolene Fox, RN
[Clinical Poster] Clinical Topic: Use of aliases in the registration of unidentified trauma patients and missteps when entering data into our electronic data linkage system have intermittently posed risks to patient safety at this Level I trauma center. The intent of this project was to identify vulnerabilities in our medical processes and develop strategies to improve patient safety. To accomplish this goal, we used the VA National Center for Patient Safety Healthcare Failure Mode and Effects Analysis (HFMEA) tool. This tool has been documented to proactively identify system weaknesses, which is used to reduce error.

Implementation: In April 2006, a multidisciplinary task force met monthly for a period of nine months to review all reported errors and near-miss events over a 5-year period. The team included staff from the emergency department, emergency preparedness, laboratory/blood bank, surgery, pharmacy, flight team, radiology, quality control, and patient account services personnel, as well as intensive care nurses, nursing supervisor, and acute care floor nurses. Using process flow diagramming and the HFMEA Decision Tree, team members evaluated errors and near-miss events. They also interviewed and observed staff in connection with the day-to-day process and work-flow of registration and electronic data linkage. This data is incorporated into the analysis to provide needed detail and variation in work routine. Task force members new to the HFMEA process received ongoing education during the analysis. Reported and estimated failure scenarios/weaknesses of our current registration and electronic data linkage processes were organized into a Hazard Scoring Matrix in which each potential "failure mode" received a hazard score (i.e., severity rating multiplied by probability rating). A score of eight or greater indicates a probability for failure that place patients at greatest risk.

Outcomes: Failure modes receiving a score of eight or greater, and which subsequently received priority action, included the following processes: (1) failure to place name band on patient before making specimen label, with potential for wrong treatment or test; (2) failure of nurse to place name band on patient in a timely manner, with potential for wrong or misidentification of patient or wrong test/treatment; (3) failure to delay electronic data linkage before all pending lab/diagnostic tests completed, resulting in treatment delay or results dumped into an irretrievable file; and (4) failure to give correct patient information during electronic data linkage, resulting in treatment delay and potential for incorrect lab/radiographic results. Changes implemented to address these problems included educating staff on correct procedure for electronic data linkage, clarification of linkage timing and designation of responsible personnel. Recommendations were made to develop electronic medical record functionality that would search records by alias or unknown identity and that would automatically generate and manage aliases. As for the FMEA analysis, we found that during the analysis, task force members new to the process and unfamiliar with correct procedure tended to look for "quick fix" solutions. Consequently, these individuals received ongoing education on how to evaluate events in a broader perspective. More specifically, during the analysis, they learned how to review reported failures and processes that led to those failures and how to proactively predict failure scenarios and identify inherent risks. Our current performance improvement process includes a monthly review of all system weaknesses, failures and near-miss events. This dynamic process allows us to determine if the implemented processes have been successful. In most instances of failure, we found that employees did not follow the approved process changes. The department manager now reviews each reported failure in detail with staff who do not comply with the policy, as written. In each case, the scenario is reviewed, both individually, and in department meetings, to reinforce adherence to correct procedures. Recommendations: One of the goals of health care is to protect patients from adverse events that could potentially cause them harm. The HFMEA process is designed to proactively identify system weaknesses before an adverse event occurs. By using this process, emergency departments can systematically identify potential patient risk and implement appropriate actions to improve the safety of their trauma patient populations.
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleFailure Mode and Effects Analysis (FMEA) of the Trauma Patient Registration Processen_GB
dc.identifier.urihttp://hdl.handle.net/10755/162651-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Failure Mode and Effects Analysis (FMEA) of the Trauma Patient Registration Process</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2007</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Day, Suzanne, RN, BSN, MA</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">LDS Hospital</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Trauma Program Manager</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">Eighth Ave. and C Street, Salt Lake City, UT, 84092, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">(801) 408-3631</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">sue.day@intermountainmail.org</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Jolene Fox, RN</td></tr><tr><td colspan="2" class="item-abstract">[Clinical Poster] Clinical Topic: Use of aliases in the registration of unidentified trauma patients and missteps when entering data into our electronic data linkage system have intermittently posed risks to patient safety at this Level I trauma center. The intent of this project was to identify vulnerabilities in our medical processes and develop strategies to improve patient safety. To accomplish this goal, we used the VA National Center for Patient Safety Healthcare Failure Mode and Effects Analysis (HFMEA) tool. This tool has been documented to proactively identify system weaknesses, which is used to reduce error.<br/><br/>Implementation: In April 2006, a multidisciplinary task force met monthly for a period of nine months to review all reported errors and near-miss events over a 5-year period. The team included staff from the emergency department, emergency preparedness, laboratory/blood bank, surgery, pharmacy, flight team, radiology, quality control, and patient account services personnel, as well as intensive care nurses, nursing supervisor, and acute care floor nurses. Using process flow diagramming and the HFMEA Decision Tree, team members evaluated errors and near-miss events. They also interviewed and observed staff in connection with the day-to-day process and work-flow of registration and electronic data linkage. This data is incorporated into the analysis to provide needed detail and variation in work routine. Task force members new to the HFMEA process received ongoing education during the analysis. Reported and estimated failure scenarios/weaknesses of our current registration and electronic data linkage processes were organized into a Hazard Scoring Matrix in which each potential &quot;failure mode&quot; received a hazard score (i.e., severity rating multiplied by probability rating). A score of eight or greater indicates a probability for failure that place patients at greatest risk.<br/><br/>Outcomes: Failure modes receiving a score of eight or greater, and which subsequently received priority action, included the following processes: (1) failure to place name band on patient before making specimen label, with potential for wrong treatment or test; (2) failure of nurse to place name band on patient in a timely manner, with potential for wrong or misidentification of patient or wrong test/treatment; (3) failure to delay electronic data linkage before all pending lab/diagnostic tests completed, resulting in treatment delay or results dumped into an irretrievable file; and (4) failure to give correct patient information during electronic data linkage, resulting in treatment delay and potential for incorrect lab/radiographic results. Changes implemented to address these problems included educating staff on correct procedure for electronic data linkage, clarification of linkage timing and designation of responsible personnel. Recommendations were made to develop electronic medical record functionality that would search records by alias or unknown identity and that would automatically generate and manage aliases. As for the FMEA analysis, we found that during the analysis, task force members new to the process and unfamiliar with correct procedure tended to look for &quot;quick fix&quot; solutions. Consequently, these individuals received ongoing education on how to evaluate events in a broader perspective. More specifically, during the analysis, they learned how to review reported failures and processes that led to those failures and how to proactively predict failure scenarios and identify inherent risks. Our current performance improvement process includes a monthly review of all system weaknesses, failures and near-miss events. This dynamic process allows us to determine if the implemented processes have been successful. In most instances of failure, we found that employees did not follow the approved process changes. The department manager now reviews each reported failure in detail with staff who do not comply with the policy, as written. In each case, the scenario is reviewed, both individually, and in department meetings, to reinforce adherence to correct procedures. Recommendations: One of the goals of health care is to protect patients from adverse events that could potentially cause them harm. The HFMEA process is designed to proactively identify system weaknesses before an adverse event occurs. By using this process, emergency departments can systematically identify potential patient risk and implement appropriate actions to improve the safety of their trauma patient populations.</td></tr></table>en_GB
dc.date.available2011-10-27T10:31:49Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:31:49Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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