title: Using failure mode effects and criticality analysis for high-risk processes at three community hospitals.
abstract: BACKGROUND
  An applied research firm collaborated with staff at three community hospitals to apply Failure Mode Effects and Criticality Analysis (FMECA) to reduce the occurrence of adverse events associated with high-risk processes. The collaboration team, which developed its own FMECA approach, performed FMECAs for six processes, including prevention of patient falls, correct medication ordering and delivery of solid oral medication, and correct blood type transfusion for adult medical surgery patients.
  The hospitals followed eight specific steps to gather data, conduct FMECA sessions, and identify medical process weaknesses and risk reduction measures. Worksheets, including each step of the system process, success criteria, possible failure modes, causes of failure, frequency of failure, consequence of failure, and safeguards placed to avoid failure, were used to capture information during the FMECA sessions.
  
  
  CONCLUSIONS
  On the basis of identified weaknesses, along with cost and other administrative considerations, medical process improvements were devised. Rules for devising improvements included improvements that help prevent the failure mode were better than those that mitigate the consequences, passive features that prevent failures were better than administrative controls, and improvements with the highest reliability were favored.
authors.affiliation: Battelle Pacific Northwest Division, Richland, Washington, USA. Garill.Coles@pnl.gov
authors.forename: Garill
authors.initials: G
authors.lastname: Coles
authors.forename: Becky
authors.initials: B
authors.lastname: Fuller
authors.forename: Kathleen
authors.initials: K
authors.lastname: Nordquist
authors.forename: Anita
authors.initials: A
authors.lastname: Kongslie
mesh_terms: D000058:Accidental Falls / Q000517:prevention & control; D000328:Adult; D003299:Cooperative Behavior; D017408:Guidelines as Topic; D006764:Hospitals, Community / Q000458:organization & administration*; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D019300:Medical Errors / Q000517:prevention & control; D008508:Medication Errors / Q000517:prevention & control; D011785:Quality Assurance, Health Care; D017751:Safety Management / Q000379:methods*; D014481:United States