HYPOTHESIS: Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures. DESIGN: Failure mode and effect analysis. SETTING: Academic research. PARTICIPANTS: A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled. MAIN OUTCOME MEASURES: A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree. RESULTS: The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes. CONCLUSIONS: Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.
HYPOTHESIS: Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures. DESIGN: Failure mode and effect analysis. SETTING: Academic research. PARTICIPANTS: A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled. MAIN OUTCOME MEASURES: A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree. RESULTS: The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes. CONCLUSIONS: Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.
Authors: Nick Sevdalis; Helen W L Wong; Sonal Arora; Kamal Nagpal; Andrew Healey; George B Hanna; Charles A Vincent Journal: Surg Endosc Date: 2012-04-27 Impact factor: 4.584
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Authors: Ann Schoofs Hundt; Jean A Adams; J Andrew Schmid; Linda M Musser; James M Walker; Tosha B Wetterneck; Stephen V Douglas; Bonnie L Paris; Pascale Carayon Journal: Int J Med Inform Date: 2012-05-16 Impact factor: 4.046