Use of healthcare failure mode and effect analysis (HFMEA) to quantify risks of the human milk feeding process.
The complexity of the expressed breast milk feeding process in the neonatal intensive care unit was not fully appreciated until we used a healthcare failure mode and effect analysis. This approach identified latent risks and provided semiquantitative estimates of the effectiveness of recommendations. Findings demonstrated nursing interruptions and multitasking requirements contributed to risk, emphasizing the need for focused and isolated expressed breast milk handling to improve patient safety and outcomes.
Division of Systems and Procedures (Dr Zhang), Department of Nursing (Mss LaFleur, Ballweg, Mulholland, Wild, Shedenhelm, Stirn, and Fjerstad), Quality Management Services (Ms Gannon), and Department of Internal Medicine (Dr Morgenthaler), Mayo Clinic, Rochester, Minnesota.
Beilei Belinda
BB
Zhang
Elizabeth A
EA
LaFleur
Diane D
DD
Ballweg
Kristi L
KL
Mulholland
Jodi A
JA
Wild
Heidi J
HJ
Shedenhelm
Susan L
SL
Stirn
Janet L
JL
Gannon
Kelly A
KA
Fjerstad
Timothy I
TI
Morgenthaler
D061186:Breast Milk Expression; D064648:Critical Care Nursing / Q000592:standards*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000592:standards*; D019300:Medical Errors / Q000517:prevention & control*; D008895:Milk, Human; D008910:Minnesota; D061214:Patient Safety; D011785:Quality Assurance, Health Care / Q000379:methods*; D058996:Quality Improvement; D018570:Risk Assessment