title: Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.
abstract: A multidisciplinary team from the University of Wisconsin Hospital and Clinics transplant program used failure mode and effects analysis to proactively examine opportunities for communication and handoff failures across the continuum of care from organ procurement to transplantation. The team performed a modified failure mode and effects analysis that isolated the multiple linked, serial, and complex information exchanges occurring during the transplantation of one solid organ. Failure mode and effects analysis proved effective for engaging a diverse group of persons who had an investment in the outcome in analysis and discussion of opportunities to improve the system's resilience for avoiding errors during a time-pressured and complex process.
authors.affiliation: University of Wisconsin, Madison, USA. dsteinberger@uwhealth.org
authors.forename: Dina M
authors.initials: DM
authors.lastname: Steinberger
authors.forename: Stephen V
authors.initials: SV
authors.lastname: Douglas
authors.forename: Mark S
authors.initials: MS
authors.lastname: Kirschbaum
mesh_terms: D015984:Causality; D003144:Communication Barriers; D003266:Continuity of Patient Care / Q000458:organization & administration*; D003627:Data Interpretation, Statistical; D006801:Humans; D007400:Interprofessional Relations; D019300:Medical Errors / Q000517:prevention & control* / Q000523:psychology / Q000706:statistics & numerical data; D016377:Organ Transplantation / Q000592:standards; D010043:Outcome and Process Assessment, Health Care / Q000458:organization & administration*; D010348:Patient Care Team / Q000458:organization & administration; D018570:Risk Assessment / Q000458:organization & administration; D017751:Safety Management / Q000458:organization & administration; D013597:Systems Analysis; D013997:Time Factors; D009927:Tissue and Organ Procurement / Q000458:organization & administration*; D017749:Total Quality Management / Q000458:organization & administration*; D014922:Wisconsin; D016526:Workload