Using Failure Mode and Effects Analysis to identify hazards within resuscitation

摘要

Study objective: Resuscitation is a fast paced highly complex process which makes considerable demands on the resuscitation team; even minor errors and failures may reduce the chance of a successful outcome. Failure Mode Effects Analysis (FMEA) is a team-based, systematic proactive step-by-step process which identifies failure modes/hazards within the process which could compromise the progression and outcome of the process and highlights where improvements need to be implemented to mitigate failures from occurring. We applied FMEA to the resuscitation process and highlight specific areas within the currently accepted resuscitation protocol which require further assessment.Methods: We followed the procedure for FMEA outlined by the Joint Commission but with some modifications of the basic process. Our modified approach made use of 16 individual interviews with healthcare professionals experienced in resuscitation and focus groups in order to gain a more detailed understanding of the different perspectives on the resuscitation process. The interviews prioritised potential failures that exist in the on-ward resuscitation process which enabled the team to identify specific areas which require further assessment and improvements.Results: In total the FMEA found 28 failure modes that carry a degree of risk that require action. It was found that staff perceived failure modes that relate to the patient's airway, breathing or circulation as ones which would result in a severe effect on the patient's outcome, and those that relate to tasks involved in the running of the process were often perceived as likely to occur.Conclusion: The modified FMEA approach proved practical, and was well received by clinicians within the context of resuscitation and fundamentally highlighted areas where quality improvements are necessary. Our research group and design team at the Helen Hamlyn Centre used the FMEA to develop design cues and technology innovations to address current issues of design duplicity that would be incorporated into a new ‘intelligent resuscitation trolley’ which we foresee will support the team by improving communication, coordination and overall efficiency.