Failure modes and effect analysis to develop transfer protocols in the management of COVID-19 patients

Sevastru, Stefan; Curtis, Sam; Kole, Lola Emanuel; Nadarajah, Premala

doi:10.1016/j.bja.2020.04.055

Cited by 9 publications

(10 citation statements)

References 4 publications

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“…Organization of Safety Walkrounds [ 6 ] and observations in the field represented key support for front-line staff in the application of the new guidelines, protocols, new procedures and for the identification of hazards. Most of the analyses were conducted using ad hoc checklists and proactive risk analysis methods as the Failure Mode and Effect Analyses [ 7 ] and simulations of new emergency scenarios and clinical pathways.…”

Section: Applied Hfe Solutions For Improvementmentioning

confidence: 99%

HFE at the frontiers of COVID-19. Human factors/ergonomics to support the communication for safer care in Italy during the COVID-19 pandemic

Albolino

Dagliana

Tanzini

et al. 2021

International Journal for Quality in Health Care

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Italy was the first country after China to be affected by COVID-19. The wave of the emergency found our country unprepared to cope with the surge of patients going to first aid departments to seek assistance in the almost complete paralysis of community health. Human factors and ergonomics (HFE) can effectively contribute to, and improve the effectiveness of, a pandemic response working on several key areas: training, adapting workflows and processes, restructuring teams and tasks, effective mechanisms and tools for communication, engaging patients and families and learning from failures and successes. In Italy, HFE expertise has been able to provide our healthcare systems with some easy-to-realize solutions (particularly dedicated to improving communication, team work and situational awareness) in order to cope with the need for rapid adaptations to new and unknown scenarios: ensuring information and communication continuity in the different levels of the healthcare system; identifying hazard opportunity through risk management tool; providing training through simulation; organizing regular briefing and debriefing; enhancing the reporting and learning system as an informal way of communicating adverse events and supporting information campaign and education initiatives for the public.

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Section: Applied Hfe Solutions For Improvementmentioning

confidence: 99%

HFE at the frontiers of COVID-19. Human factors/ergonomics to support the communication for safer care in Italy during the COVID-19 pandemic

Albolino

Dagliana

Tanzini

et al. 2021

International Journal for Quality in Health Care

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“…It is aimed at prioritization of corrective measures. 10 – 12 Traditional healthcare failure modes and effect analysis requires the assembly of a designated team to review each step within a complex task, identification of potential failure modes, and the assignment of a numerical value to each for severity, probability of occurrence, and detectability. When these values are combined, a risk priority number is generated, which helps guide prioritization of interventions.…”

Section: Failure Modes and Effect Analysis Process Mapping And On-smentioning

confidence: 99%

Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis with In Situ Simulation

et al. 2020

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Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care–intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.

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“…2 In addition, they undertook a point-of-care simulation for the transfer of an obstetric patient with COVID-19 from isolation to theatre using the failure modes and effects analysis (FMEA) tool to guide safety. 9 The SOP was modified in response to our clinical experience and changes in guidance from Public Health England, the Obstetric Anaesthetists Association and the Royal College of Obstetrics and Gynaecology. [10][11][12] A key development at the time was the decision to treat all delivering women as suspected COVID-19 due to lack of available testing.…”

Section: Introductionmentioning

confidence: 99%

Failure modes and effects analysis to assess COVID-19 protocols in the management of obstetric emergencies

Curtis

Flower

Emanuel-Kole

et al. 2020

BMJ Simul Technol Enhanc Learn

Self Cite

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The Royal Free Hospital is one of four High Consequence Infectious Disease centres in England and as of the end of May 2020, seven women were confirmed COVID-19 peri-delivery. We developed a standard operating procedure (SOP) for suspected and confirmed COVID-19 women undergoing operative delivery. This was revised in response to our ongoing clinical experience and changes in guidance from medical and public health organisations. Following 10 weeks of clinical practice, we formally tested the SOP using point-of-care simulation to enable optimisation for a potential second surge. Our high-fidelity simulation of a COVID-19-positive parturient requiring an emergency caesarean was facilitated by the simulation team in our obstetric unit. It was designed to test the performance and safety of our SOP as well as staff performance. We used the Failure Modes and Effect Analysis tool (a systematic, prospective method of process mapping) to identify how a complex task might fail and assess the relative impact of different failures. The decision-to-delivery was 17 minutes, which we considered to be successful. However, a number of operational deficiencies were identified. The main failures related to lack of situational awareness, ill-fitting personal protective equipment and difficulties communicating between theatre and the neonatal teams located outside, posing serious potential risks to safe neonatal care. Subsequently, we have modified our SOP to include a communication check, implemented communication training for the neonatal team and organised further simulation training for theatre staff unfamiliar with COVID-19 considerations.

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Failure modes and effect analysis to develop transfer protocols in the management of COVID-19 patients

Cited by 9 publications

References 4 publications

HFE at the frontiers of COVID-19. Human factors/ergonomics to support the communication for safer care in Italy during the COVID-19 pandemic

HFE at the frontiers of COVID-19. Human factors/ergonomics to support the communication for safer care in Italy during the COVID-19 pandemic

Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis with In Situ Simulation

Failure modes and effects analysis to assess COVID-19 protocols in the management of obstetric emergencies

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