Improving the Safety of Chemotherapy Administration: An Oncology Nurse-Led Failure Mode and Effects Analysis

Ashley, Laura; Dexter, Rachel; Marshall, Fay; McKenzie, Brenda L.; Ryan, Maggie; Armitage, Gerry

doi:10.1188/11.onf.e436-e444

Cited by 24 publications

(59 citation statements)

References 42 publications

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“…Although a major strength of the PMOS is that it allows identification of contributory factors from a patients’ perspective, it must be recognised that it does not capture all possible contributory factors. It must therefore be used in conjunction with other tools, such as staff safety culture surveys and Failure Modes Effects Analysis,33 to explore upstream organisational failures.…”

Section: Discussionmentioning

confidence: 99%

Developing a patient measure of safety (PMOS)

Giles

Lawton

Din³

et al. 2013

BMJ Qual Saf

126

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Section: Discussionmentioning

confidence: 99%

Developing a patient measure of safety (PMOS)

Giles

Lawton

Din³

et al. 2013

BMJ Qual Saf

126

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“…, Ashley et al . ). Given the central and persistent role of communication failures in adverse events in healthcare (Sutcliffe et al .…”

Section: Discussionmentioning

confidence: 97%

“…, Ashley et al . ). Despite the extensive use of FMEA in healthcare, it appears that FMEA has not to date been used to appraise and improve the quality and safety of a social care process.…”

Section: Introductionmentioning

confidence: 97%

“…As healthcare has espoused industry-derived approaches to safety, so too has it looked to adopt industry-based methods and tools for assessing and improving safety. One tool that has received considerable attention is Failure Mode and Effects Analysis (FMEA), a risk assessment methodology used to identify potential vulnerabilities in complex, high-risk processes and to generate corrective strategies to counteract these before they result in adverse events (Ashley et al 2011). A multidisciplinary team of subject matter experts typically undertakes a FMEA over a series of team meetings, and although several variants exist, FMEA has a formal, sequential process (shown in Box 1).…”

Section: Introductionmentioning

confidence: 99%

“…FMEA has been successfully used to proactively assess and improve the safety of a range of different healthcare processes in numerous settings and countries including medicines management, blood transfusion and organ transplantation (e.g. Burgmeier et al 2002, Steinberger et al 2009, Ashley et al 2011. Despite the extensive use of FMEA in healthcare, it appears that FMEA has not to Box 1 Five stages of a Failure Mode and Effects Analysis (FMEA) (Ashley et al 2011) 1 Map the process under evaluation to identify its component steps 2 Identify failure modes (potential errors) for each process step 3 Numerically score the failure modes to prioritise them according to the risk they pose 4 Identify possible causes for the highest-risk failure modes (and based on these) 5 Generate corrective actions to address them date been used to appraise and improve the quality and safety of a social care process.…”

Section: Introductionmentioning

confidence: 99%

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Recognising and referring children exposed to domestic abuse: a multi-professional, proactive systems-based evaluation using a modified Failure Mode and Effects Analysis (FMEA)

Ashley

Armitage

Taylor

2016

Health Soc Care Community

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AcknowledgementsWe would like to thank the NSPCC and LSCB and all the members of the FMEA teamespecially Willma King who facilitated the team meetings with sensitivity and intelligence. Also, Wesley Powley-Baker and Di Jerwood who both provided excellent support in the development of this project, and Beth Fylan Gwynn for assistance with the feedback interviews. Source of Funding: National Society for the Prevention of Cruelty to Children Conflict of InterestNone 2 2 AbstractFailure Modes and Effects Analysis (FMEA) is a prospective quality assurance methodology, increasingly used in health care, which identifies potential vulnerabilities in complex, high risk processes and generates remedial actions. We aimed, for the first time, to apply FMEA in a social care context to evaluate the process for recognising and referring children exposed to domestic abuse within one Midlands city safeguarding area in England. A multidisciplinary, multi-agency team of ten front line professionals undertook the FMEA, using a modified methodology, over seven group meetings. The FMEA included mapping out the process under evaluation to identify its component steps, identifying failure modes (potential errors) and possible causes for each step, and generating corrective actions. In this paper we report the output from the FMEA, including illustrative examples of the failure modes and corrective actions generated. We also present an analysis of feedback from the FMEA team and provide future recommendations for the use of FMEA in appraising social care processes and practice. Although challenging, the FMEA was unequivocally valuable for team members and generated a significant number of corrective actions locally for the safeguarding board to consider in its response to children exposed to domestic abuse. KeywordsChild safeguarding; child protection; domestic violence; practitioner research; multidisciplinary work; failure mode and effects analysis 3 3 Bullet PointsWhat is known about this topic  Failure Modes and Effects Analysis (FMEA) is a prospective quality assurance methodology increasingly used in health care to identify potential vulnerabilities in complex, high risk processes and generate remedial actions. FMEA has not to date been used to evaluate and improve the quality and safety of social care processes. What this paper adds First study to explore the feasibility and utility of using a modified FMEA methodology to evaluate an aspect of a child safeguarding social care process (recognising and referring children exposed to domestic abuse). Reports a summary of the FMEA output, evaluative feedback from the FMEA team, and recommendations for using a prospective systems approach in appraising social care processes and practice.

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FMEA for Proactive Healthcare Risk Analysis: A Systematic Literature Review

Liu

2019

Improved FMEA Methods for Proactive Healthcare Risk Analysis

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Improving the Safety of Chemotherapy Administration: An Oncology Nurse-Led Failure Mode and Effects Analysis

Abstract: Bradford Scholars -how to deposit your paper Overview Copyright check• Check if your publisher allows submission to a repository.• Use the Sherpa RoMEO database if you are not sure about your publisher's position or email openaccess@bradford.ac.uk.

Cited by 24 publications

References 42 publications

Developing a patient measure of safety (PMOS)

Developing a patient measure of safety (PMOS)

Recognising and referring children exposed to domestic abuse: a multi-professional, proactive systems-based evaluation using a modified Failure Mode and Effects Analysis (FMEA)

FMEA for Proactive Healthcare Risk Analysis: A Systematic Literature Review

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