Use of Failure Mode and Effects Analysis for Proactive Identification of Communication and Handoff Failures from Organ Procurement to Transplantation

Steinberger, Dina; Douglas, Stephen V.; Kirschbaum, Mark

doi:10.1177/152692480901900303

Cited by 22 publications

(17 citation statements)

References 6 publications

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“…The US VA has developed an FMEA version tailored to health care, health-care failure mode and effects analysis. 73 During the past few years, FMEA has been used in health care to assess the risks associated with, for example, organ procurement and transplantation, 74 intravenous drug infusions, 75 blood transfusion 76 and communication in the ED. 77 The approach to risk analysis adopted in this project to identify and describe the risks associated with handover failures in the emergency care pathway follows largely the standard FMEA approach for qualitative hazard identification and risk analysis.…”

Section: Principles Of Risk Analysismentioning

confidence: 99%

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research

Sujan

Spurgeon

Inada-Kim

et al. 2014

Health Services and Delivery Research

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Copyright and reuse:The Warwick Research Archive Portal (WRAP) makes this work by researchers of the University of Warwick available open access under the following conditions. Copyright © and all moral rights to the version of the paper presented here belong to the individual author(s) and/or other copyright owners. To the extent reasonable and practicable the material made available in WRAP has been checked for eligibility before being made available. Copies of full items can be used for personal research or study, educational, or not-forprofit purposes without prior permission or charge. Provided that the authors, title and full bibliographic details are credited, a hyperlink and/or URL is given for the original metadata page and the content is not changed in any way. This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (www.publicationethics.org/). PublisherEditorial contact: nihredit@southampton.ac.ukThe full HS&DR archive is freely available to view online at www.journalslibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journals Library website: www.journalslibrary.nihr.ac.uk Criteria for inclusion in the Health Services and Delivery Research journalReports are published in Health Services and Delivery Research (HS&DR) if (1) they have resulted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. HS&DR programmeThe Health Services and Delivery Research (HS&DR) programme, part of the National Institute for Health Research (NIHR), was established to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which were merged in January 2012.The HS&DR programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services including costs and outcomes, as well as research on implementation. The programme will enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evaluative research to improve health services.For more information about the HS&DR programme please visit the website: www.netscc.ac.uk/hsdr/ This reportThe research reported in this issue of the journal was funded by the HS&DR programme or one of its proceeding programmes as project number 10/1007/26. The contractual start date was in April 2011. The final report began editorial review in January 2013 and was accepted for publication in May 2013. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors' report and would like to thank the reviewers for their constructive comments on the final report document. However, th...

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Section: Principles Of Risk Analysismentioning

confidence: 99%

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research

Sujan

Spurgeon

Inada-Kim

et al. 2014

Health Services and Delivery Research

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“…6 Organizational and/or environmental factors contributing to communication error include alarms, interruptions, 7 and the lack of a predetermined process to guide shift report. 9 A basic concept to guide the development of safety improvement initiatives includes standardizing and simplifying the structure of tasks to minimize the demand on working memory, planning, or problem solving. 9 A basic concept to guide the development of safety improvement initiatives includes standardizing and simplifying the structure of tasks to minimize the demand on working memory, planning, or problem solving.…”

mentioning

confidence: 99%

Developing a Standardized Tool to Improve Nurse Communication During Shift Report

Jukkala

James

Autrey

et al. 2012

Journal of Nursing Care Quality

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Standardization of communication has been suggested as an effective approach to improve communication during patient handoffs such as shift report. Using the clinical microsystem framework, unit leaders and nursing staff developed and pilot tested the medical intensive care unit communication tool. Findings from the pilot study indicated that perceived communication among nurses in general and communication specific to shift report improved significantly following implementation of the tool.

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“…Although some teams obtain a consensus on failure mode scores through group discussion, 3,16,17 others calculate the mathematical central tendency (mean or median) of team members' independently assigned scores, 18Y20 and still others use various mixes of these 2 methods. 7Y10 However, one aspect of the method on which there is a notable lack of information and guidance is failure mode scoring, and specifically the process by which FMEA teams assign failure mode scores.…”

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confidence: 99%

Failure Mode and Effects Analysis

Ashley

Armitage

2010

Journal of Patient Safety

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Objectives: To empirically compare 2 different commonly used failure mode and effects analysis (FMEA) scoring procedures with respect to their resultant failure mode scores and prioritization: a mathematical procedure, where scores are assigned independently by FMEA team members and averaged, and a consensus procedure, where scores are agreed on by the FMEA team via discussion.Methods: A multidisciplinary team undertook a Healthcare FMEA of chemotherapy administration. This included mapping the chemotherapy process, identifying and scoring failure modes (potential errors) for each process step, and generating remedial strategies to counteract them. Failure modes were scored using both an independent mathematical procedure and a team consensus procedure.Results: Almost three-fifths of the 30 failure modes generated were scored differently by the 2 procedures, and for just more than one-third of cases, the score discrepancy was substantial. Using the Healthcare FMEA prioritization cutoff score, almost twice as many failure modes were prioritized by the consensus procedure than by the mathematical procedure.Conclusions: This is the first study to empirically demonstrate that different FMEA scoring procedures can score and prioritize failure modes differently. It found considerable variability in individual team members' opinions on scores, which highlights the subjective and qualitative nature of failure mode scoring. A consensus scoring procedure may be most appropriate for FMEA as it allows variability in individuals' scores and rationales to become apparent and to be discussed and resolved by the team. It may also yield team learning and communication benefits unlikely to result from a mathematical procedure.

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Use of Failure Mode and Effects Analysis for Proactive Identification of Communication and Handoff Failures from Organ Procurement to Transplantation

Cited by 22 publications

References 6 publications

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research

Developing a Standardized Tool to Improve Nurse Communication During Shift Report

Failure Mode and Effects Analysis

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