Central Service Association Of Ontario Fahrenheit 270
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Transcript of Central Service Association Of Ontario Fahrenheit 270
Central Service Association Central Service Association Of OntarioOf Ontario
Fahrenheit 270Fahrenheit 270
Failure Modes and Failure Modes and Effects AnalysisEffects Analysis
ISMP CANADA VisionISMP CANADA Vision Independent nonprofit Canadian organizationIndependent nonprofit Canadian organization
Established for:Established for: the collection and analysis of medication error reports the collection and analysis of medication error reports
andand
the development of recommendations for the the development of recommendations for the
enhancement of patient safety.enhancement of patient safety.
Serves as a national resource for promoting safe Serves as a national resource for promoting safe
medication practices throughout the health care medication practices throughout the health care
community in Canada.community in Canada.
ISMP Canada Mission:ISMP Canada Mission:
Committed to the safe use of medication Committed to the safe use of medication through improvement in drug distribution through improvement in drug distribution and drug delivery system design.and drug delivery system design.
Collaborate with healthcare practitioners Collaborate with healthcare practitioners and institutions, schools, professional and institutions, schools, professional organizations, pharmaceutical industry organizations, pharmaceutical industry and regulatory & government agencies to and regulatory & government agencies to provide education about adverse drug provide education about adverse drug events and their preventionevents and their prevention
ObjectivesObjectives
To introduce the principle and application of To introduce the principle and application of FMEA tool/process FMEA tool/process
To discuss its application in healthcare To discuss its application in healthcare facilitiesfacilities
To briefly review the FMEA processTo briefly review the FMEA process
Failure Mode and Effects Failure Mode and Effects AnalysisAnalysis
ISMP Canada one day workshopISMP Canada one day workshop 4 exercises of 45 – 60 minutes4 exercises of 45 – 60 minutes Practce on your own issuesPractce on your own issues
Human Factors Engineering Human Factors Engineering 101101
HFE:HFE: a discipline concerned with design of systems, a discipline concerned with design of systems, tools, processes, machines that take into tools, processes, machines that take into account human capabilities, limitations, and account human capabilities, limitations, and characteristicscharacteristics
Human Factors EngineeringHuman Factors Engineering
Research and practical applications Research and practical applications designed to improve the interface of designed to improve the interface of humans with systemshumans with systems
Develops practical design principles that Develops practical design principles that account for the psychological and physical account for the psychological and physical characteristics of peoplecharacteristics of people
Human Factors Engineering Human Factors Engineering PrinciplesPrinciples
Simplify key processesSimplify key processes Standardize work processesStandardize work processes Anticipate that human make errorsAnticipate that human make errors Use checklistsUse checklists Improve label designImprove label design Promote effective team functioningPromote effective team functioning
Constraint:
Hydromorphone 10 mg
was removed
The “Brain Flip” Needed in The “Brain Flip” Needed in HealthCareHealthCare
EngineeringEngineering Begin with premise that Begin with premise that
anything can and will go anything can and will go wrongwrong
Don’t expect humans to Don’t expect humans to perform perfectly or perform perfectly or without variationwithout variation
Design systems Design systems accordingly and are accordingly and are proactiveproactive
Health CareHealth Care Errors are the result of Errors are the result of
human failureshuman failures Humans generally Humans generally
perform flawlesslyperform flawlessly Perfect performance is Perfect performance is
the expectationthe expectation Use re-training, and Use re-training, and
punishment to root out punishment to root out bad applesbad apples
Human Factors – Human Factors – Guiding PrincipleGuiding Principle
Fit the task or tool to Fit the task or tool to the human, not the the human, not the other way around.other way around.
High Reliability High Reliability Organizations (HRO) Organizations (HRO)
CharacteristicsCharacteristics
Collective preoccupation with the Collective preoccupation with the possibility of failure”possibility of failure”
Expect to make errors and train their Expect to make errors and train their workforce to recognize and recover workforce to recognize and recover from themfrom them
Continual rehearsal of familiar scenarios Continual rehearsal of familiar scenarios of failureof failure
FMEA DefinitionFMEA Definition
FMEA is a FMEA is a team-basedteam-based systematicsystematic and and proactiveproactive approach for identifying the ways approach for identifying the ways that a process or design can that a process or design can failfail, , whywhy it it might fail, the might fail, the effectseffects of that failure and of that failure and how it can be made saferhow it can be made safer..
FMEA focuses on how and when a system FMEA focuses on how and when a system will fail, not IF it will fail.will fail, not IF it will fail.
Why FMEA?Why FMEA?
Brings analysis logic into the hospitalBrings analysis logic into the hospital Is a proactive approach for quality and safetyIs a proactive approach for quality and safety Initiates system fixes before a patient dies or Initiates system fixes before a patient dies or
is injured is injured Makes systems more “robust” and enhances Makes systems more “robust” and enhances
performanceperformance Makes systems more “fault tolerant”Makes systems more “fault tolerant” Focuses on systems, not individualsFocuses on systems, not individuals
Everyday FMEAEveryday FMEAYesYes NoNo
Do you take actions to prevent yourself from Do you take actions to prevent yourself from being late to work?being late to work?
Do you take a ‘shortcut’ when you see traffic Do you take a ‘shortcut’ when you see traffic building up in a familiar place?building up in a familiar place?
Do you try to distinguish ‘big problems’ from Do you try to distinguish ‘big problems’ from ‘little problems’?‘little problems’?
Do you see the possibility of eliminating Do you see the possibility of eliminating some problems, but need a better way to some problems, but need a better way to show that to people?show that to people?
FMEA versus RCAFMEA versus RCA (when to use)(when to use)
FMEAFMEA = = Future (preventative)Future (preventative)
RCA RCA == Retrospective (after the event or Retrospective (after the event or close call)close call)
FMEA OriginsFMEA Origins
FMEA in use more than 40 years beginning in FMEA in use more than 40 years beginning in aerospace in the 1960saerospace in the 1960s
1970s and 1980s used in other fields such as 1970s and 1980s used in other fields such as nuclear power, aviation, chemical, electronics nuclear power, aviation, chemical, electronics and food processing fields ( High Reliability and food processing fields ( High Reliability Organizations)Organizations)
Automotive industry requires it from suppliers, Automotive industry requires it from suppliers, reducing the after-the-fact corrective actionsreducing the after-the-fact corrective actions
FMEA is a tool to:FMEA is a tool to:
Analyze a process to see where it is Analyze a process to see where it is likely to fail.likely to fail.
See how changes you are See how changes you are considering might affect the safety of considering might affect the safety of the process.the process.
CCHSA Patient Safety Goals CCHSA Patient Safety Goals 20052005
Create a culture of safety within the Create a culture of safety within the organizationorganization The organization has in place a formal The organization has in place a formal
team/committee whose sole focus is patient team/committee whose sole focus is patient safety, and that does one proactive RCA or safety, and that does one proactive RCA or FMEA a year.FMEA a year.
FMEA StepsFMEA Steps
Step 1Step 1 Select process and assemble the Select process and assemble the teamteam
Step 2 Step 2 Diagram the processDiagram the process
Step 3 Step 3 Brainstorm potential failure modes Brainstorm potential failure modes and determine their effectsand determine their effects
Step 4 Step 4 Identify the causes of failure modesIdentify the causes of failure modes
FMEA Steps (cont)FMEA Steps (cont)
Step 5Step 5 Prioritize failure modesPrioritize failure modes
Step 6 Step 6 Redesign the processesRedesign the processes
Step 7 Step 7 Analyze and test the changesAnalyze and test the changes
Step 8Step 8 Implement and monitor the Implement and monitor the redesigned processesredesigned processes
Step 1
Select a high
risk process and assemble
the team
Step 2 Step 3
FMEA Process Steps
Select a high-risk processSelect a high-risk process
Internal data – aggregate Internal data – aggregate data, significant individual data, significant individual eventsevents
Sentinel EventsSentinel Events
CCHSA Patient Safety CCHSA Patient Safety GoalsGoals
ISMP CanadaISMP Canada
Executive buy-inExecutive buy-in
Select processes with high potential for having an adverse impact on the
safety of individuals served.
High Risk Processes - High Risk Processes - DefinitionDefinition
Those processes in which a failure of Those processes in which a failure of some type is most likely to jeopardize some type is most likely to jeopardize the safety of the individuals served by the safety of the individuals served by the health care organization. Such the health care organization. Such process failures may result in a sentinel process failures may result in a sentinel event.event.
High Risk Processes - High Risk Processes - ExamplesExamples
Medication Use Medication Use
Operative and other proceduresOperative and other procedures
Blood use and blood componentsBlood use and blood components
RestraintsRestraints
Infection controlInfection control
Care provided to high-risk populationCare provided to high-risk population
Emergency or resuscitation careEmergency or resuscitation care
Assemble a teamAssemble a team LeaderLeader FacilitatorFacilitator Scribe / RecorderScribe / Recorder Process expertsProcess experts
Include all areas Include all areas involved in the processinvolved in the process
““Outsider” /Naïve personOutsider” /Naïve person 6-10 optimal number6-10 optimal number
Step 1
Select a high risk process
and assemble the team
Step 2
Diagram the Process
Step 3
FMEA Process Steps
Diagram (flow chart) the Diagram (flow chart) the processprocess
Define beginning and end of process under analysis
Chart the process as it is normally done
Using the collective process knowledge of the team, a flow chart is sketched.
Why diagram the process?Why diagram the process?
Diagrams clarify things between membersDiagrams clarify things between members
Narrows the topic – goes from broad topic Narrows the topic – goes from broad topic e.g. narcotic use process to narrow topic e.g. narcotic use process to narrow topic e.g. morphine removed from narcotic e.g. morphine removed from narcotic drawerdrawer
Narcotic Drug Use ProcessNumber Basic Steps
Receive drugs from Pharmacy vendor
Administer drug to patient
Document drug administration and
record waste
Remove from stock one dose at a time as patients request
medication
Dispense to patient care area
Check drugs into pharmacy
1 2 3
4 5 6
Narcotic Drug Use ProcessSelect One Portion of
Process at a Time to Diagram
Receive drugs from Pharmacy vendor
Administer drug to patient
Document drug administration and
record waste
Remove from stock one dose at a time as patients request
medication
Dispense to patient care area
Check drugs into pharmacy
1 2 3
4 5 6
Narcotic Drug Use ProcessDiagram the Sub-Process Steps
Receive request from Patient Care
Area
Technician assembles drug(s)
Technician hand carries to the
Patient Care Area
Pharmacist checks drug against
request
Narcotic and request set out to
be checked
Technician pulls drug from Narcotic
vault / cabinet
Step 1
Select a high risk process
and assemble the team
Step 2
Diagram the Process
Step 3
Brainstorm
potential
failure modes
FMEA Process Steps
Brainstorm potential failure Brainstorm potential failure modes modes
1. People
2. Materials
3. Equipment
4. Methods
5. Environment
Failure modes answer the WHAT could go wrong question
Handy HintsHandy Hints
Failure Modes are the WHATs that could Failure Modes are the WHATs that could go wronggo wrong
Failure Mode Causes are the “WHY”sFailure Mode Causes are the “WHY”s May be more than one cause for each May be more than one cause for each
failurefailure
Narcotic Drug Use ProcessPotential Failure Modes
Receive request from Patient Care Area
Technician assembles
drug(s)
Technician hand carries to the Patient Care
Area
Pharmacist checks drug
against request
Narcotic and request set out to
be checked
Technician pulls drug from
Narcotic vault / cabinet
3A 3B 3C 3D 3E 3F
Request never received
Pharmacy is closed
Request is blank
Potential Failure ModesProcess Steps
Technician doesn’t pull drug
Technician pulls wrong quantity
Technician forgets to set out on counter
Drug diverted while sitting out on counter
Drug slips off the counter or falls through crack
Pharmacist doesn’t check
Pharmacist checks only part of request
Pharmacist checks inaccurately
Technician grabs partial
Technician grabs order for closed unit
Technician mixes up drugs and requests
Technician drops drug or request
Technician hijacked on way to patient care area
Technician mixes up drugs and requests
Technician pulls wrong drug
1 1 1 1 11
2 2 2 2 2 2
333333
Step 1
Select a high risk process
and assemble the team
Step 2
Diagram the Process
Step 3
Failure
Modes
FMEA Process Steps
Step 4
EffectsAnd
Causes
IdentifyIdentify
Effects of the Failure ModesEffects of the Failure Modes
Review each failure mode and identify the Review each failure mode and identify the effects of the failure should it occureffects of the failure should it occur
May be 1 effect or > 1May be 1 effect or > 1
Must be thorough because it feeds into the Must be thorough because it feeds into the risk ratingrisk rating
IfIf failure occurs, failure occurs, then whatthen what are the are the consequencesconsequences
Identify root causes of Identify root causes of failure modesfailure modes
Focus on systems & Focus on systems & processes, not individualsprocesses, not individuals
Asks why?, not who?Asks why?, not who?
Prospective application of Prospective application of RCARCA
Critical to identify Critical to identify allall root root causes and their causes and their interactionsinteractions
Single Point WeaknessSingle Point Weakness
• A step so critical that its failure will result in a A step so critical that its failure will result in a system failure or adverse eventsystem failure or adverse event
• Single point weaknesses and existing control Single point weaknesses and existing control measures “modify” the scoringmeasures “modify” the scoring Single point weaknesses should all be acted uponSingle point weaknesses should all be acted upon IF effective control measures are in place, it would IF effective control measures are in place, it would
cancel the need to take further action (risk is cancel the need to take further action (risk is mitigated)mitigated)
Step 1
Select a high risk
process and assemble the team
Step 2
Diagram the
Process
Step 3
Brainstorm potential failure
modes and determine
their effects
FMEA Process Steps
Step 4
Identify causes of
failure modes
Step 5
Prioritize Failure Modes
Prioritize failure modesPrioritize failure modes
Score severity of effect of failure modeScore severity of effect of failure mode
Score frequency of occurrence of failure Score frequency of occurrence of failure modemode
Score likelihood of detection Score likelihood of detection (detectability) of failure prior to the (detectability) of failure prior to the impact of the effect being realizedimpact of the effect being realized
SeveritySeverity
The seriousness and severity of the effect (to the The seriousness and severity of the effect (to the process or system or patient) of a failure if it should process or system or patient) of a failure if it should
occur.occur.
Score based upon a “reasonable worst case scenario”Score based upon a “reasonable worst case scenario”
Severity Description ScoreNo effect 1
Slight 2Moderate 3
Major 4Severe / Catastrophic 5
FrequencyFrequency Also known as occurrence – it is the Also known as occurrence – it is the
likelihood or number of times a specific likelihood or number of times a specific failure (mode) could occurfailure (mode) could occur
Frequency Description ScoreYearly 1
Monthly 2Weekly 3Daily 4
Hourly 5
DetectabilityDetectabilityThe likelihood of detecting a failure or the effect The likelihood of detecting a failure or the effect
of a failure BEFORE it occursof a failure BEFORE it occurs
Many events are detectable or obvious after Many events are detectable or obvious after they occur but that is not a FMEA detectable event they occur but that is not a FMEA detectable event
by definition.by definition.
Detectability Description ScoreAlways 1Likely 2
Unlikely 3Never 4
Examples of DetectabilityExamples of Detectability
Break away locksBreak away locks Emergency drug boxes with pop up pinEmergency drug boxes with pop up pin Ampoules Ampoules Low battery alarmLow battery alarm
Calculate the Risk Priority NumberCalculate the Risk Priority Number
Determine the impact of the failure on the patient or Determine the impact of the failure on the patient or the system using the severity, frequency and the system using the severity, frequency and detectability parametersdetectability parameters
Multiply three scores to obtain a Risk Priority Number Multiply three scores to obtain a Risk Priority Number (RPN) or Criticality Index (CI)(RPN) or Criticality Index (CI)
Also assign priority to those with a high severity score Also assign priority to those with a high severity score even though the RPN may be relatively loweven though the RPN may be relatively low
RPN = Severity x Occurrence x Detection
Step 1
Select a high risk
process and assemble the team
Step 2
Diagram the
Process
Step 3
Brainstorm potential failure
modes and determine
their effects
FMEA Process Steps
Step 4
Identify causes of
failure modes
Step 5
Prioritize Failure Modes
Step 6
Redesign the
Process
Redesign the processRedesign the process
Apply strategies to decrease Apply strategies to decrease occurrence, decrease occurrence, decrease severity, or increase severity, or increase detectiondetection
Goal:Goal: prevent harm to the prevent harm to the patientpatient
Simplification, automation, Simplification, automation, standardization, fail-safe standardization, fail-safe mechanisms, forcing mechanisms, forcing functions, redundancyfunctions, redundancy
Evaluating Redesign Evaluating Redesign Options Options
Don’t just pick training and policy development. Don’t just pick training and policy development. They are basic actions but not very strong or They are basic actions but not very strong or long lastinglong lasting
Go for the permanent fixes when possibleGo for the permanent fixes when possible
Elimination of the step or the function is a very Elimination of the step or the function is a very strong actionstrong action
Most actions are really controls on the systemMost actions are really controls on the system
Sometimes your team might have to accept Sometimes your team might have to accept some of the failure modes as “un-fixable”some of the failure modes as “un-fixable”
Rank Order of Error Reduction Rank Order of Error Reduction Strategies Strategies
1.1. Forcing functions and constraintsForcing functions and constraints
2.2. Automation and computerizationAutomation and computerization
3.3. Simplify, standardize and differentiateSimplify, standardize and differentiate
4.4. Reminders, check lists and double check Reminders, check lists and double check systemssystems
5.5. Rules and policiesRules and policies
6.6. EducationEducation
7.7. InformationInformation
8.8. Punishment (no value)Punishment (no value)
Step 1
Select a high risk
process and assemble the team
Step 2
Diagram the
Process
Step 3
Brainstorm potential failure
modes and determine
their effects
FMEA Process Steps
Step 4
Identify causes of
failure modes
Step 5
Prioritize Failure Modes
Step 6
Redesign the
Process
Step 7
Analyze and Test the Changes
Analyze and test the Analyze and test the changeschanges
Conduct FMEA of re-Conduct FMEA of re-designed processdesigned process
Use simulation testing Use simulation testing whenever possiblewhenever possible
Conduct pilot testing Conduct pilot testing in one area or one in one area or one sectionsection
Step 1
Select a High Risk
Process and Assemble a
Team
Step 2
Diagram the
Process
Step 3
Brainstorm Potential Failure
Modes and Determine
Their Effects
FMEA Process Steps
Step 4
Identify Causes of
Failure Modes
Step 5
Prioritize Failure Modes
Step 6
Redesign the
Process
Step 7
Analyze and Test the Changes
Step 8
Implement and
Monitor the Redesigned Processes
Implement and monitor the Implement and monitor the redesigned processredesigned process
Communicate Communicate reasons for process reasons for process changeschanges
Find change agentsFind change agents Define process and Define process and
outcome measuresoutcome measures Share resultsShare results Monitor over timeMonitor over time
Gains using FMEAGains using FMEA
Safety minded culture Safety minded culture Proactive problem resolutionProactive problem resolution Robust systems Robust systems Fault tolerant systemsFault tolerant systems Lower waste and higher qualityLower waste and higher quality
‘‘Emphasis on prevention Emphasis on prevention may reduce risk of may reduce risk of
harm to both patients harm to both patients and staff.’and staff.’
Failure Modes and Effects Analysis (FMEA), IHI and Quality Health Failure Modes and Effects Analysis (FMEA), IHI and Quality Health Care.org, 2003Care.org, 2003
ReferencesReferences
McDermott- The Basics of FMEAMcDermott- The Basics of FMEA
Stamatis – Failure Mode Effect Analysis: FMEA Stamatis – Failure Mode Effect Analysis: FMEA from Theory to Execution (2from Theory to Execution (2ndnd ed) ed)
JCAHO – Failure Mode and Effects Analysis in JCAHO – Failure Mode and Effects Analysis in Health Care. Proactive Risk ReductionHealth Care. Proactive Risk Reduction
Manasse, Thompson (Lin, Burkhardt) -Logical Manasse, Thompson (Lin, Burkhardt) -Logical Application of Human Factors In Process and Application of Human Factors In Process and Equipment Design (in press).Equipment Design (in press).