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    HFMEA

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    arvinddhotre3131
    This document discusses healthcare failure mode and effect analysis (HFMEA). HFMEA is a technique used to identify potential failures in processes and their likely consequences. It aims to prevent adverse events. The document outlines the HFMEA process, provides an example of analyzing alarms in an intensive care unit, and compares HFMEA to root cause analysis.

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    HFMEA

    Uploaded by

    arvinddhotre3131
    236 views14 pages
    This document discusses healthcare failure mode and effect analysis (HFMEA). HFMEA is a technique used to identify potential failures in processes and their likely consequences. It aims to prevent adverse events. The document outlines the HFMEA process, provides an example of analyzing alarms in an intensive care unit, and compares HFMEA to root cause analysis.

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    This document discusses healthcare failure mode and effect analysis (HFMEA). HFMEA is a technique used to identify potential failures in processes and their likely consequences. It aims to prevent adverse events. The document outlines the HFMEA process, provides an example of analyzing alarms in an intensive care unit, and compares HFMEA to root cause analysis.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    236 views14 pages

    HFMEA

    Uploaded by

    arvinddhotre3131
    This document discusses healthcare failure mode and effect analysis (HFMEA). HFMEA is a technique used to identify potential failures in processes and their likely consequences. It aims to prevent adverse events. The document outlines the HFMEA process, provides an example of analyzing alarms in an intensive care unit, and compares HFMEA to root cause analysis.

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    Healthcare Failure Mode and Effect AnalysisSM

    Edward J. Dunn, MD, MPH VA National Center for Patient Safety edward.dunn@med.va.gov www.patientsafety.gov

    Location in our VA NCPS Curriculum Toolkit


    Content
    - Patient Safety Introduction - Human Factors Engineering
    Instructor Preparation -Swift and Long Term Trust - Selling the Curriculum - Etc

    -HFMEA ppt & exercise


    Alternative Education Formats
    - Pt Safety Case Conference (M&M) - Pt Safety on Rounds (Modulettes)

    - HFMEA participation
    - Etc

    Why use prospective analysis?  Aimed at prevention of adverse events  Doesnt require previous bad experience (patient harm)  Makes system more robust  JCAHO requirement

    JCAHO Standard LD.5.2 Effective July 2001


    Leaders ensure that an ongoing, proactive program for identifying risks to patient safety and reducing medical/health care errors is defined and implemented.      Identify and prioritize high-risk processes Annually, select at least one high-risk process Identify potential failure modes For each failure mode, identify the possible effects For the most critical effects, conduct a root cause analysis

    Who uses failure mode effect analysis?


     Engineers worldwide in:  Aviation  Nuclear power  Aerospace  Chemical process industries  Automotive industries  Has been around for over 40 years  Goal has been, and remains, to prevent accidents from occurring

    Healthcare Version - HFMEASM


    Combines:
    Traditional Failure Mode Effect Analysis Hazard Analysis and Critical Control Point VA Root Cause Analysis

    Adapted and Tested in Healthcare Settings


    163 VA hospitals (with some success) Still a complex process/time commitment (see NIH)

    The Healthcare Failure Mode Effect Analysis Process Step 1- Define the Topic Step 2 - Assemble the Team Step 3 - Graphically Describe the Process Step 4 - Conduct the Analysis Step 5 - Identify Actions and Outcome Measures

    HFMEATM Hazard Scoring Matrix Severity


    Catastrophic Major 12 9 6 3 Moderate 8 6 4 2 Minor 4 3 2 1

    Probability

    Frequent Occasional Uncommon Remote

    16 12 8 4

    Does this hazard involve a sufficient likelihood of occurrence and severity to warrant that it be controlled? (e.g. Hazard Score of 8 or higher)

    HFMEATM Decision Tree


    NO NO

    YES

    Is this a single point weakness in the process? (e.g. failure will result in system failure) (Criticality) YES

    Does an Effective Control Measure exist for the identified hazard?

    YES STOP

    NO Is the hazard so obvious and readily apparent that a control measure is not warranted? (Detectability)

    YES

    NO

    PROCEED TO HFMEA STEP 5

    ICU Alarm Example


    Monitoring Patient Alarms in ICU Isolation Room 1 2 3 4

    Patient is being Transferred to ICU Isolation Room

    Connect to necessary physiological monitor and equipment

    Provide care and monitor Alarms

    Intervene as appropriate

    Sub Process Steps A. Apply transfer acceptance checklist B. Determine type of isolation and post C. Determine parameters to be monitored D. Gather and calibrate monitor and accessories (e.g. transducers)

    Sub Process Steps A. Don Personal Protective Equipment B. Connect to ventilator if appropriate C. Connect monitoring devices to patient D. Set Alarm parameters as appropriate E. Test Alarm Broadcast

    Sub Process Steps A. Periodically check monitor status B. Respond to alarms

    Sub Process Steps A. Verify validity of alarm B. Reconnect equipment (if necessary) C. Medically intervene (if necessary) D. Silence alarm E. Readjust alarm parameters (if necessary)

    ICU Alarm Example

    3A

    3B

    Periodically check monitor status

    Respond to alarms

    Failure Modes 3A1 Did not check status 3A2 Misread or misinterpret 3A3 Partially check

    Failure Modes 3B1 Did not respond 3B2 Respond slowly or late

    ICU Alarm Example


    HFMEA Subprocess Step: 3B1 - Respond to Alarms
    HFMEA Step 4 - Hazard Analysis

    HFMEA Step 5 - Identify Actions and Outcomes Action Type (Control, Accept, Eliminate)

    Probability

    Haz Score

    Frequent

    3B1 Don't respond to alarm

    Catastrophi Severity c

    16

    16

    Catastrophic

    Occasional

    3B1b

    12

    Catastrophic Catastrophic Catastrophic

    Occasional

    3B1c

    12

    Frequent

    3B1d

    Didn't hear alarm; remote location (doors closed to isolation room) Caregiver busy; alarm does not broadcast to backup

    16

    Occasional

    12

    Biomedical Engineer

    3B1e

    Enable equipment feature that w ill alarm in adjacent room(s) to notify caregiver or partner(s).

    Immediate; w ithin 2 w orking days; complete by mm/dd/yyyy

    Biomedical Engineer Yes

    Didn't hear; alarm volume too low

    Biomedical Engineer Yes

    Didn't hear; care giver left immediate area

    Alarms w ill be broadcast to the central station w ithin 4 months; complete by mm/dd/yyyy Set alarm volume on isolation Immediate; w ithin 2 room equipment such that the w orking days; low est volume threshold that can complete by be adjusted by staff is alw ays mm/dd/yyyy audible outside the room. See 3B1b See 3B1b

    Nurse Manager

    3B1a

    Catastrophic

    Frequent

    Ignored alarm (desensitized)

    Proceed?

    Evaluate failure mode before determining potential causes

    Potential Causes

    Single Point Weakness? Exi sting Control Measure ? Detectability

    Actions or Rationale for Stopping

    Outcome Measure

    Reduce unw anted alarms by: changing alarm parameter to fit patient physiological condition and replace electrodes w ith better quality that do not become detached Alarms w ill be broadcast to Central Station w ith retransmission to pagers provided to care staff.

    Unw anted alarms on floor are reduced by 75% w ithin 30 days of implementation.

    Management Concurrence
    Yes Yes

    Failure Mode: First

    Scoring

    Decision Tree Analysis

    Person Responsible

    Blow-up of One Line


    Failure Mode: 3B1a - Crucial Alarm Ignored and Patient Decompensated
    Failure Mode Cause
    Severity Frequency

    Action

    Outcome Measure Unwanted alarms on floor are reduced by 75% within 30 days of implementation

    Ignored alarm Catastr Frequent Reduce unwanted (desensitized) ophic alarms by: changing alarm parameter to fit patient physiological condition and replace electrodes with better quality that do not become detached

    HFMEA & RCA


    Similarities
    Interdisciplinary team Develop flow diagram Systems focus Actions & Outcome measures Scoring matrix (severity/probability) Triage questions, cause & effect diag., brainstorming

    Differences
    Preventive v. reactive Analysis of Process v. chronological case Choose topic v. case Prospective (what if) analysis Detectability & Criticality in evaluation Emphasis on testing intervention

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