title: Application of a proactive risk analysis to emergency department sickle cell care.
abstract: BACKGROUND
  Patients with sickle cell disease (SCD) often seek care in emergency departments (EDs) for severe pain. However, there is evidence that they experience inaccurate assessment, suboptimal care, and inadequate follow-up referrals. The aim of this project was to 1) explore the feasibility of applying a failure modes, effects and criticality analysis (FMECA) in two EDs examining four processes of care (triage, analgesic management, high risk/high users, and referrals made) for patients with SCD, and 2) report the failures of these care processes in each ED.
  
  
  METHODS
  A FMECA was conducted of ED SCD patient care at two hospitals. A multidisciplinary group examined each step of four processes. Providers identified failures in each step, and then characterized the frequency, impact, and safeguards, resulting in risk categorization.
  
  
  RESULTS
  Many "high risk" failures existed in both institutions, including a lack of recognition of high-risk or high-user patients and a lack of emphasis on psychosocial referrals. Specific to SCD analgesic management, one setting inconsistently used existing analgesic policies, while the other setting did not have such policies.
  
  
  CONCLUSIONS
  FMECA facilitated the identification of failures of ED SCD care and has guided quality improvement activities. Interventions can focus on improvements in these specific areas targeting improvements in the delivery and organization of ED SCD care. Improvements should correspond with the forthcoming National Heart, Lung and Blood-sponsored guidelines for treatment of patients with sickle cell disease.
authors.affiliation: Duke University School of Medicine, Duke Medical Center, Department of Surgery, Division of Emergency Medicine, Durham, North Carolina ; Duke School of Nursing, Duke University Medical Center, Durham, North Carolina.
authors.forename: Victoria L
authors.initials: VL
authors.lastname: Thornton
authors.affiliation: Northwestern University, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
authors.forename: Jane L
authors.initials: JL
authors.lastname: Holl
authors.affiliation: Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina.
authors.forename: David M
authors.initials: DM
authors.lastname: Cline
authors.affiliation: Duke University School of Medicine, Duke Medical Center, Department of Surgery, Division of Emergency Medicine, Durham, North Carolina.
authors.forename: Caroline E
authors.initials: CE
authors.lastname: Freiermuth
authors.affiliation: Duke School of Nursing, Duke University Medical Center, Durham, North Carolina.
authors.forename: Dori T
authors.initials: DT
authors.lastname: Sullivan
authors.affiliation: Duke School of Nursing, Duke University Medical Center, Durham, North Carolina ; Duke University School of Medicine, Duke Medical Center, Department of Surgery, Division of Emergency Medicine, Durham, North Carolina.
authors.forename: Paula
authors.initials: P
authors.lastname: Tanabe
mesh_terms: D000755:Anemia, Sickle Cell / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D059408:Pain Management; D011446:Prospective Studies; D058996:Quality Improvement; D012017:Referral and Consultation / Q000706:statistics & numerical data; D018570:Risk Assessment; D014218:Triage