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Failure Mode and Effects Analysis: A Useful Tool for Risk Identification and Injury Prevention

      Careful, in-depth, and timely analysis of a medical error occurring in the ED setting is an essential element of any solid safety plan, regardless of whether such an event actually has caused patient harm. Conducting a root cause analysis or another type of retrospective investigation helps teach us valuable lessons about how to redesign our systems in health care and prevent the error from occurring the next time. But how do we know that a “redesigned” system or a change in a process will work, or for that matter, how do we know that the new process will be any safer than the one we abandoned? The answer lies within a lesser-used proactive risk management technique called Failure Mode and Effects Analysis (FMEA).
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      References

        • Senders JW
        • Senders SJ
        Health care failure mode and effects analysis.
        in: Cohen MR Medication errors. American Pharmaceutical Association, Washington2007
        • Spath PL
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        in: Spath P Proactively error-proofing health care processes: error reduction in health care. AHA Press, Chicago2000: 179-198
      1. Cohen MR, Senders J, Davis NM. Failure mode and effects analysis: a novel approach to avoiding dangerous medication errors and accidents. Hosp Pharm 1994;29:319-24, 326-28, 330.

      2. Failure Mode and Effects Analysis Institute for Healthcare Improvement.
        (Available at:) (Accessed February 19, 2007)
      3. Joint Commission on Accreditation of Healthcare Organizations. Hospital accreditation standards (2006). Oak Brook Terrace (IL): Joint Commission Resources; 2006. p. 255-6, 261-77.

        • Joint Commission on Accreditation of Healthcare Organizations
        Failure mode and effect analysis in healthcare: proactive risk reduction. Joint Commission Resources, Oak Brook Terrace (IL)2002
      4. Institute for Safe Medication Practices. ISMP Medication Safety Alert! Failure mode and effects analysis can help guide error prevention efforts. 2001;6(21):1.

      5. Institute for Safe Medication Practices. ISMP Canada Safety Bulletin. Failure mode and effects analysis (FMEA): proactively identifying risk in healthcare. Institute for Safe Medication Practices Canada. 2006;6(8):1-2.

      Biography

      Susan Paparella, Bux-Mont Chapter, is Director for Consulting Services, Institute for Safe Medication Practices (ISMP*), Huntingdon Valley, Pa, and a member of ENA's LUNAR III Workgroup.