using failure modes and effects analysis to evaluate “home meds” failures in surgical patients...
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Using failure modes and effects Using failure modes and effects analysis to evaluate “home analysis to evaluate “home meds” failures in surgical meds” failures in surgical
patientspatients
Fred M. Blanchard, Pharm.D.Fred M. Blanchard, Pharm.D.Virginia Commonwealth UniversityVirginia Commonwealth UniversityPatient Safety Fellowship ProgramPatient Safety Fellowship Program
May 1, 2003May 1, 2003
PurposePurpose
Introduce FMEA methodologyIntroduce FMEA methodology Incorporate FMEA into Performance Incorporate FMEA into Performance
Improvement and Patient Safety Improvement and Patient Safety EffortsEfforts
Apply FMEA and evaluate “home Apply FMEA and evaluate “home meds” failuresmeds” failures
MethodsMethods Establish a teamEstablish a team FOCUS PDSAFOCUS PDSA FMEA TrainingFMEA Training FMEAFMEA Define, Prioritize, Measure FailuresDefine, Prioritize, Measure Failures InterveneIntervene Re-measureRe-measure
““Home Meds” TeamHome Meds” Team
Dale Bosiger, Pre-op Dale Bosiger, Pre-op EducationEducation
Debra Coulter, PACUDebra Coulter, PACU Lynn Harris, SurgicareLynn Harris, Surgicare Nadine Gilmore, Nadine Gilmore,
PharmacyPharmacy Linda Lange, Nursing Linda Lange, Nursing
Policy and ProcedurePolicy and Procedure
Sherry Payne, Sherry Payne, Orthopedic UnitOrthopedic Unit
Randall Puckett, Randall Puckett, PharmacyPharmacy
Kim Woodley, Kim Woodley, Quality Support Quality Support Services (PI)Services (PI)
Fred Blanchard, Fred Blanchard, PharmacyPharmacy
FMEAFMEA
Originally intended for prospective Originally intended for prospective identification of failuresidentification of failures
Applied retrospectively as a stand Applied retrospectively as a stand alone process in the healthcare alone process in the healthcare environmentenvironment
Also applied as a tool in FOCUS PDSAAlso applied as a tool in FOCUS PDSA
PI and FMEA SimilaritiesPI and FMEA Similarities
FOCUS PDSAFOCUS PDSA Find a ChallengeFind a Challenge Organize a TeamOrganize a Team Clarify ProcessClarify Process Understand the Understand the
Variation & Select a Variation & Select a ProcessProcess
P-D-S-AP-D-S-A
FMEAFMEA Define TopicDefine Topic Assemble TeamAssemble Team Describe ProcessDescribe Process Hazard AnalysisHazard Analysis
Action/Outcome Action/Outcome MeasuresMeasures
Graphic Description of Graphic Description of ProcessProcess
SURGEONREFERRAL FOR
SURGERY
PRE-OP TESTINGAND TEACHING
SURGICALADMISSION
SURGERYTRANSFER TO
UNIT OR FLOORS
CHANGE LEVELOF CARE
DISCHARGEHOME
1 2 3 4 5
6
7
Subsystem Steps and Subsystem Steps and CausesCauses
2A. OFFICESTAFF SCHEDPREOP VISIT
AND SURG
2B. CALL TO VBHOFFICE TOSCHEDULE
2C. SURGERYSCHEDULED
2D. OFFICE STAFFSCHEDULES PREOP
VISIT
2E. OFFICE STAFFTELL PT TO BRING
MEDS
2F. PT ARRIVES FORPREOP VISIT,COMPLETESWORKSHEET
2G. NURSETRANSCRIBES TO
ASSESSMENT FORM
2I.ANESTHESIOLOGIST
INTERVIEWSPATIENT
2H. NURSE REVIEWSMEDS WITH PATIENT
AND GIVESINSTRUCTIONS
1. didn't tell patient
2. not emphasized
3. not understood
4.office staff doesn'tunderstand importance
1. pt. doesn't show
2. didn't bring anymeds
3. didn't bring all meds
4. brought list
5. gave verbalmedication history
6. brought medswithout labels
1. illegible
2. incorrecttranscription
3. misunderstoodpatient intentionwhenpatient wrote meddirections
1. gaps in medicationhistory not clarified withphysician
1. gaps in medicationhistory not clarified withother physicians
2. ignores nurserecommnedation toadvise patient
3. not available after1530
Failure ModeFailure Mode
2g1 Nurse transcription from patient 2g1 Nurse transcription from patient form to assessment sheet is illegibleform to assessment sheet is illegible
Failure AnalysisFailure Analysis
Potential CausePotential Cause
2g1(e) Form not suitable for writing 2g1(e) Form not suitable for writing complete medication instructions complete medication instructions including drug, strength, route, and including drug, strength, route, and frequencyfrequency
Hazard Analysis 2g1(e)Hazard Analysis 2g1(e)
Severity = MajorSeverity = Major Probability = FrequentProbability = Frequent Hazard Score = 12Hazard Score = 12
Decision Tree 2g1(e)Decision Tree 2g1(e)Does the hazardwarrant control?
(Score > 8)
Is this a single pointweakness?
(Failure=System Failure)
Does an effective controlmeasure exist?
Is the hazard so obviousthat a control measure is
not warranted?
STOP
Determine Action andOutcome Measures
NO
YES
YES
NO
NO
NO
YES
Action TypeAction Type
ControlControlAcceptEliminate
Action and Outcome Action and Outcome MeasuresMeasures
Measure “error” rates at baselineMeasure “error” rates at baseline Develop a new form; combine stepsDevelop a new form; combine steps Perform a trialPerform a trial Measure post intervention “error” Measure post intervention “error”
ratesrates
PREOP
NURSE
ADMIT
RECORD
OLD
FORM
{ {
Baseline Measure of Current Baseline Measure of Current ProcessProcess
Retrospectively reviewed 94 charts-Retrospectively reviewed 94 charts-all same day surgeries over a three all same day surgeries over a three week periodweek period
Baseline MeasurementsBaseline MeasurementsBeforBeforee
Charts with “Home Meds” documented pre-opCharts with “Home Meds” documented pre-op 94%94%Charts with any order to renew “Home Meds” Charts with any order to renew “Home Meds” post-oppost-op
69%69%
Post-op “Home Meds” order “qualified”Post-op “Home Meds” order “qualified” 84%84%Post-op “Home Meds” orders “complete”Post-op “Home Meds” orders “complete” 34%34%Post-op orders that were clarifiedPost-op orders that were clarified 44%44%Average number of “Home-Meds” pre-opAverage number of “Home-Meds” pre-op 5.75.7Average number of “Home Meds” renewed Average number of “Home Meds” renewed post-oppost-op
2.72.7
Drug, Strength, Frequency, Route info pre-opDrug, Strength, Frequency, Route info pre-op 91%91%Drug, Strength, Frequency, Route info post-opDrug, Strength, Frequency, Route info post-op 98%98%Discrepancies post-opDiscrepancies post-op 22%22%
RESUME
HOME
MEDS
FORM
NEW
FORM
{
Post Intervention Utilization of Post Intervention Utilization of Combined Home Meds FormCombined Home Meds Form
Retrospectively reviewed 51 charts-Retrospectively reviewed 51 charts-all same day surgeries over a two all same day surgeries over a two week periodweek period
New form used by nursing staff 45 New form used by nursing staff 45 times (88%)times (88%)
New form used by nursing and New form used by nursing and physician staff 35 times (78%)physician staff 35 times (78%)
ResultsResultsBeforBeforee
AfterAfter
Charts with “Home Meds” documented pre-opCharts with “Home Meds” documented pre-op 94%94% 100%100%Charts with any order to renew “Home Meds” Charts with any order to renew “Home Meds” post-oppost-op
69%69% 100%100%
Post-op “Home Meds” order “qualified”Post-op “Home Meds” order “qualified” 84%84% 100%100%Post-op “Home Meds” orders “complete”Post-op “Home Meds” orders “complete” 34%34% 100%100%Post-op orders that were clarifiedPost-op orders that were clarified 44%44% 0%0%Average number of “Home-Meds” pre-opAverage number of “Home-Meds” pre-op 5.75.7 6.36.3Average number of “Home Meds” renewed Average number of “Home Meds” renewed post-oppost-op
2.72.7 4.94.9
Drug, Strength. Frequency, Route info pre-opDrug, Strength. Frequency, Route info pre-op 91%91% 99%99%Drug, Strength, Frequency, Route info post-opDrug, Strength, Frequency, Route info post-op 98%98% 99%99%Discrepancies post-opDiscrepancies post-op 22%22% 0%0%
DiscussionDiscussion
Advantages of using FMEA in the Advantages of using FMEA in the context of FOCUS PDSAcontext of FOCUS PDSA Identification of failuresIdentification of failures Greater depth of analysisGreater depth of analysis Improved prioritization of selected Improved prioritization of selected
processesprocesses LimitationsLimitations
Time consumingTime consuming Reserve for critical processesReserve for critical processes
DiscussionDiscussion
Home Meds Reorder ProcessHome Meds Reorder Process Combining pre-op medication history with post-Combining pre-op medication history with post-
op order set:op order set: Reduced process variationReduced process variation Improved pre-op documentationImproved pre-op documentation Increased frequency of post-op renewalIncreased frequency of post-op renewal Improved the completeness of post-op ordersImproved the completeness of post-op orders Reduced calls to clarify ordersReduced calls to clarify orders Increased probability that meds taken at home were Increased probability that meds taken at home were
continued post-opcontinued post-op Reduced the number of post-op order discrepanciesReduced the number of post-op order discrepancies
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