Abstract :
SSUE: In 2003, our CEO charged department heads with completing two proactive risk-reduction projects a year. The purpose was to foster patient safety throughout the facility. Leadership was educated in FMECA (failure, mode, effect, criticality, analysis), a process that promotes a systematic thinking in terms of what could go wrong, how bad might it be, and how can we prevent it from happening.
PROJECT: Infection control chose FMECAs based on practices that had many steps requiring human intervention of different disciplines that would be high risk if they failed: 1) management of employees post exposure to bloodborne pathogens (BBPs), 2) safe placement of patients requiring isolation for communicable diseases, and 3) identification of patients readmitted with resistant organisms. Teams were formed for each project to ensure that all disciplines involved in that process were participating. Using flowcharts, practices and procedures were dissected to identify the likelihood of process failures for each step in the FMECA.
RESULTS: Based on the FMECAs, practices were redesigned to achieve potential error reductions. Examples of process changes include: An algorithm was developed for emergency room providers to follow for BBP exposures. Orientation for incoming house staff now includes a class on transmission-based precautions. A computer program now identifies patients readmitted with a past history of resistant organisms. Multidisciplinary team members contributed ideas from different perspectives. Each team shared the results of their FMECAs at our leadership meetings for others to learn from their experiences.
LESSONS LEARNED: It is important to look at processes that appear to be safe. Just because a problem hasnʹt occurred yet, it doesnʹt mean that the process isnʹt flawed. It is impossible to eliminate all errors or design a perfect system. Focus needs to be on what allows errors to occur, rather than on who made an error. This multidisciplinary team approach helped create a culture of patient safety where everyone takes ownership.
