title: PCA oversedation: application of Healthcare Failure Mode Effect (HFMEA) Analysis.
abstract: Hospital systems utilize many varied problem-solving processes to address system improvements and ensure patient safety. The Healthcare Failure Mode Effect Analysis (HFMEA) model is one of these tools and uses a multidisciplinary team to look at processes, diagramming the steps involved to identify potential failure points. The application of the HFMEA model allowed one large health care system to address a complex process by prioritizing proactive change improvements in order to prevent postoperative patient-controlled anesthesia oversedation events. The changes implemented identified 16 failure points with a hazard score of 16 or greater. One year later, the established system HFMEA goal was met: oversedation events were reduced by 50%.
authors.affiliation: Acute Care Services, Franciscan Health System, St. Francis Hospital, Federal Way, WA, USA.
authors.forename: Pam
authors.initials: P
authors.lastname: Cronrath
authors.forename: Timothy W
authors.initials: TW
authors.lastname: Lynch
authors.forename: Linda J
authors.initials: LJ
authors.lastname: Gilson
authors.forename: Carol
authors.initials: C
authors.lastname: Nishida
authors.forename: M Colleen
authors.initials: MC
authors.lastname: Sembar
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: Spencer
authors.forename: Daidre Foote
authors.initials: DF
authors.lastname: West
mesh_terms: D016058:Analgesia, Patient-Controlled / Q000009:adverse effects* / Q000451:nursing*; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D062787:Drug Overdose; D006801:Humans; D004091:Hydromorphone / Q000008:administration & dosage*; D008508:Medication Errors / Q000517:prevention & control*; D019982:Organizational Case Studies; D010348:Patient Care Team; D011785:Quality Assurance, Health Care; D018570:Risk Assessment; D017751:Safety Management; D014861:Washington
chemical_list: D000701:Analgesics, Opioid; D004091:Hydromorphone