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The Basics of Healthcare Failure Mode and Effect Analysis
The Basics of Healthcare Failure Mode and Effect Analysis
2
Why Use FMEA?
3
Course Objectives
By the end of the course, participants will:
Understand the purpose of Healthcare FMEA
Have a conceptual understanding of the steps
of the Healthcare FMEA process
Know how to choose an appropriate topic for
analysis
Be able to successfully address the JCAHO
2001 proactive risk assessment standard
4
Failure Mode & Effect Analysis
5
Failure Mode & Effect Analysis
6
Who uses FMEA?
Historically…
Accident prevention has not been a
primary focus of hospital medicine
Misguided reliance on “faultless”
performance by healthcare
professionals
Hospital systems were not designed to
prevent or absorb errors; they just
reactively changed and were not
typically proactive
8
Rationale for FMEA in Healthcare
9
JCAHO Standard LD.5.2
Effective July 2001
10
Intent of LD.5.2
12
JCAHO Standard LD.5.2
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JCAHO Standard LD.5.2
16
Healthcare FMEA Definitions
Hazard Analysis:
The process of collecting and evaluating
information on hazards associated with
the selected process. The purpose of
the hazard analysis is to develop a list
of hazards that are of such significance
that they are reasonably likely to cause
injury or illness if not effectively
controlled.
17
Healthcare FMEA Definitions
Failure Mode:
Different ways that a process or sub-
process can fail to provide the
anticipated result.
18
HFMEA and the RCA Process
Similarities Differences
Interdisciplinary Team Process vs. chronological
Develop Flow Diagram flow diagram
Prospective (what if)
Focus on systems issues
analysis
Actions and outcome Choose topic for
measures developed evaluation
Scoring matrix
(severity/probability) Include detectability
and criticality in
Use of Triage/Triggering evaluation
questions, cause & effect Emphasis on testing
diagram, brainstorming intervention
19
HFMEA Points Out
System/Process Vulnerabilities
A B C
Identified process
issue;
focus for intervention
20
Reason’s Model of Accidents
Production
Lack of Pressures Attention
Procedures Zero fault Distractions
tolerance
Mixed Deferred
Punitive Messages Sporadic Maintenance
policies Training Clumsy
Technology
Patient
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Process Design & Organizational
Change
Process Re-Design Organizational
Redundancy Increase Constructive Feedback
and Direct Communication
Usability Testing
Teamwork
Simplification
Drive Out Fear
Fail-safe designs
Leadership Commitment
Reduce Reliance on
Memory & Vigilance
Simplify
Standardize
Checklists
Forcing Functions
Eliminate Look and Sound-
alikes
Simulate
Looser coupling of systems
22
The Healthcare Failure Modes
and Effects Process
STEP 1
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Healthcare FMEA Process
STEP 2
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Healthcare FMEA Process
26
Healthcare FMEA Process
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Healthcare FMEA Process
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Healthcare FMEA Process
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Healthcare FMEA Process
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Forms & Tools
Forms
Worksheets
Hazard Scoring Matrix
Decision Tree
31
Healthcare FMEA Process
32
Healthcare FMEA Process
2.__________________ 5.______________________
3.__________________ 6.______________________
Are different levels and types of knowledge represented on the team? YES / NO
33
HFMEA Worksheet
HFMEASubprocessstepnameandtitle
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalysis
Responsible
Management
Existing Control
Concurrence
Action
Person
Detectability
Single Point
Type
Probability
Weakness?
Haz Score
Measure ?
FailureMode: (Control
Proceed?
Severity
FirstEvaluatefailure ,
modebefore Accept,
determiningpotential Eliminat ActionsorRationale
causes PotentialCauses e) forStopping OutcomeMeasure
34
HFMEA Decision Tree
Does this hazard involve a sufficient
likelihood of occurrence and severity to
warrant that it be controlled?
Tree…
NO
YES
YES
Does an Effective Control Measure exist for the
identified hazard? STOP
NO
NO
PROCEED TO HFMEA
STEP 5
35
HFMEA Decision Tree
YES NO
36
HFMEA Decision Tree
NO
YES
37
HFMEA Decision Tree
YES
NO
STOP
38
HFMEA Decision Tree
NO
STOP
PROCEED
39
Hazard Analysis
SEVERITY RATING:
MajorEvent
CatastrophicEvent
(TraditionalFMEARatingof10-Failurecould (TraditionalFMEARatingof7–Failurecausesa
causedeathorinjury) highdegreeofcustomerdissatisfaction.)
PatientOutcome:Permanentlesseningofbodily
PatientOutcome:Deathormajorpermanent
functioning(sensory,motor,physiologic,or
lossoffunction(sensory,motor,physiologic,or
intellectual),disfigurement,surgicalintervention
intellectual),suicide,rape,hemolytictransfusion
required,increasedlengthofstayfor3ormore
reaction,Surgery/procedureonthewrongpatient
patients,increasedlevelofcarefor3ormore
orwrongbodypart,infantabductionorinfant
patients
dischargetothewrongfamily
VisitorOutcome:Hospitalizationof1or2visitors
VisitorOutcome:Death;orhospitalizationof3
StaffOutcome:Hospitalizationof1or2staffor3
ormore.
ormorestaffexperiencinglosttimeorrestricted
StaffOutcome:*Adeathorhospitalizationof3
dutyinjuriesorillnesses
ormorestaff
Equipmentor facility:**Damageequaltoor
Equipmentorfacility:**Damageequaltoor
morethan$100,000
morethan$250,000
Fire:NotApplicable–SeeModerateand
Fire:Anyfirethatgrowslargerthananincipient
Catastrophic
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Hazard Analysis
SEVERITY RATING:
MinorEvent
ModerateEvent (TraditionalFMEARatingof“1”–Failurewould
(TraditionalFMEARatingof“4”–Failurecan notbenoticeabletothecustomerandwould
beovercomewithmodificationstothe notaffectdeliveryoftheserviceorproduct.)
processorproduct,butthereisminor
performanceloss.)
PatientOutcome:Increasedlengthofstayor
increasedlevelofcarefor1or2patients
Visitor Outcome:Evaluationandtreatmentfor Patients Outcome:Noinjury,norincreased
1or2visitors(lessthanhospitalization) lengthofstaynorincreasedlevelofcare
StaffOutcome:Medicalexpenses,losttimeor Visitor Outcome:Evaluatedandnotreatment
restricteddutyinjuriesorillnessfor1or2staff requiredorrefusedtreatment
Equipment or facility:**Damagemorethan Staff Outcome:Firstaidtreatmentonlywithno
$10,000butlessthan$100,000 losttime,norrestricteddutyinjuriesnorillnesses
‡ Equipment or facility:**Damagelessthan
♦
Fire:Incipientstageorsmaller
$10,000orlossofanyutilitywithoutadverse
patientoutcome(e.g.power,naturalgas,
electricity,water,communications,transport,
heat/airconditioning).
Fire:NotApplicable–SeeModerateand
Catastrophic
41
Hazard Analysis
PROBABILITY RATING:
Frequent - Likely to occur immediately or within a short
period (may happen several times in one year)
Occasional - Probably will occur (may happen several
times in 1 to 2 years)
Uncommon - Possible to occur (may happen sometime
in 2 to 5 years)
Remote - Unlikely to occur (may happen sometime in 5 to
30 years)
42
HFMEA Hazard Scoring Matrix
Severity
Catastrophic Major Moderate Minor
Probability
Frequent 16 12 8 4
Occasional 12 9 6 3
Uncommon 8 6 4 2
Remote 4 3 2 1
43
Example - Driving to Work
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Healthcare FMEA Process
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Healthcare FMEA Process
2.__________________ 5.______________________
3.__________________ 6.______________________
Are different levels and types of knowledge represented on the team? YES / NO
46
Teaching Example
47
Teaching Example
48
Teaching Example
49
Teaching Example
1A. Hit snooze 2A. Get 3A. Find keys 4A. Coffee in
on alarm 5A. Notice 6A. Collect
coffee cupholder and take exit bag, coffee,
1B. Again, hit 3B. Find
snooze on 2B. Take wallet 4B. Bagel on 5B.Negotiate bagel
alarm shower seat turn 6B. Close
3C. Look for
1C. Get out of 2C. Find bag 4C. Listen to 5C. Find spot and lock
bed clean traffic report doors
3D. Look for 5D. Get car
1D. Find fuzzy clothes 6C. Begin
slippers coffee 4D. Choose to turn off
2D. Find route walking
3E. Shovel
shoes 6D. Return
out car
for keys 50
Teaching Example
51
Teaching Example
Failure Modes
1A(1) Turn off
alarm
1A(2) Unplug
Alarm
1A(3) Break
alarm clock
52
HFMEA Worksheet, Step 4A
HitSnoozeButton-1A
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalys
Responsible
Existing Control
is
Concurrence
Management
Action
Person
FailureMode:
Detectability
Single Point
Type
Weakness?
Probability
FirstEvaluatefailu
Haz Score
Measure ?
(Contr
Proceed?
re
Severity
modebefore ol,
determiningpotent Accept, ActionsorRation
ial PotentialCaus Elimin ale OutcomeMeasu
causes es ate) forStopping re
1A( Turnoff
1) alarm
53
HFMEA Worksheet
HitSnoozeButton-1A
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalys
Responsible
Existing Control
is
Concurrence
Management
Action
Person
FailureMode:
Single Point
Detectability
Type
Weakness?
Haz Score
Probability
FirstEvaluatefailu
Measure ?
(Contr
Proceed?
re
Severity
modebefore ol,
determiningpotent Accept, ActionsorRation
ial PotentialCau Elimin ale OutcomeMeasu
causes ses ate) forStopping re
1A( Turnoff
1) alarm
54
Step 4: Hazard Analysis
Step 4B. Determine the Severity and Probability of each
potential cause. This will lead you to the Hazard Matrix Score.
SEVERITY RATING:
CatastrophicEvent MajorEvent
(TraditionalFMEARatingof10-Failurecould (TraditionalFMEARatingof7–Failurecausesa
causedeathorinjury) highdegreeofcustomerdissatisfaction.)
PatientOutcome:Permanentlesseningofbodily
PatientOutcome:Deathormajorpermanent
functioning(sensory,motor,physiologic,or
lossoffunction(sensory,motor,physiologic,or
intellectual),disfigurement,surgicalintervention
intellectual),suicide,rape,hemolytictransfusion
required,increasedlengthofstayfor3ormore
reaction,Surgery/procedureonthewrongpatient
patients,increasedlevelofcarefor3ormore
orwrongbodypart,infantabductionorinfant
patients
dischargetothewrongfamily
Visitor Outcome:Hospitalizationof1or2visitors
Visitor Outcome:Death;orhospitalizationof3
StaffOutcome:Hospitalization
ormore.
of1or2staffor3ormorestaffexperiencinglost
StaffOutcome:*Adeathorhospitalizationof3
timeorrestricteddutyinjuriesorillnesses
ormorestaff
Equipmentor facility:**Damageequaltoor
Equipment or facility:**Damageequaltoor
morethan$100,000
morethan$250,000
Fire:NotApplicable–SeeModerateand
Fire:Anyfirethatgrowslargerthananincipient
Catastrophic
55
Step 4: Hazard Analysis
Step 4. Determine the Severity and Probability of each
potential cause. This will lead you to the Hazard Matrix Score.
PROBABILITY RATING:
56
HFMEA Hazard Scoring Matrix
Severity
Catastrophic Major Moderate Minor
Probability
Frequent 16 12 8 4
Occasional 12 9 6 3
Uncommon 8 6 4 2
Remote 4 3 2 1
57
Step 4: HFMEA Decision Tree
YES NO
58
Step 4: HFMEA Decision Tree
NO
YES
59
Step 4: HFMEA Decision Tree
YES
NO
STOP
60
Step 4: HFMEA Decision Tree
NO
STOP
PROCEED
61
HFMEA Worksheet, Steps 4B & 4C
HitSnoozeButton-1A
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalys
Responsible
Existing Control
is
Management
Concurrence
Action
Person
FailureMode:
Detectability
Single Point
Type
Weakness?
Haz Score
Probability
FirstEvaluatefailu
Measure ?
(Contr
Proceed?
re
Severity
modebefore ol,
determiningpotent Accept, ActionsorRation
ial PotentialCaus Elimin ale OutcomeMeasu
causes es ate) forStopping re
Occasional
1A( Turnoff
Major
1) alarm
----
9 N N Y
-->
62
HFMEA Worksheet, Step 5
HitSnoozeButton-1A
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnaly
Responsible
Existing Control
sis
Concurrence
Management
Action
Person
FailureMode:
Single Point
Detectability
Type
Weakness?
Haz Score
Probability
FirstEvaluatefailu
Measure ?
(Contr
Proceed?
re
Severity
modebefore ol,
determiningpoten Accept, ActionsorRation
tial PotentialCau Elimin ale OutcomeMeasu
causes ses ate) forStopping re
occasional
1A( Turnoff
major
1) alarm ---
9 --- N N Y
>
(1) oze te k in U
major
63
HFMEA PSA Example
•Process Step •Process Step •Process Step •Process Step •Process Step
64
HFMEA PSA Example
65
HFMEA PSA Example
66
HFMEA PSA Example
3G.
Enter in
CPRS
68
HFMEA PSA Example
Enter
result
Step 4A. Hazard Analysis: List potential failure (CPRS)
•Failure Mode: •Failure Mode: •Failure Mode: •Failure Mode: •Failure Mode: Failure Mode:
1.Wrong test 1.Equip. broken 1.Instr not 1.QC results 1.Mechanical 1.Computer crash
ordered 2.Wrong speed calibrated unacceptable error 2.Result entered
2.Order not 3.Specimen not 2.Bad 2.Tech error for wrong pt.
received clotted calibration 3.Computer
4.No power stored transcription
5.Wrong test error
tube 4.Result not
entered
5.Result mis-
read by tech
69
HFMEA PSA Example
Step 4B,C, D. Determine hazard score and list all the potential
causes for each potential failure mode.
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalysis
Responsible
Concurrence
Management
Existing Control
Person
Detectability
Action
Single Point
Probability
Weakness?
Haz Score
Measure ?
FailureMode: Type
Proceed?
Severity
FirstEvaluatefailure (Control,
modebefore Accept,
determiningpotential Eliminat ActionsorRationale
causes PotentialCauses e) forStopping OutcomeMeasure
Occasional
3F(1 Computer
Major
) Crash
----
9 N N Y
-->
1)a virusprocection f
---- software IRM
9 N N Y
-->
Remote
1)b t programtoreplace
--- existingequipment
2 Y Y --- N
>
70
Step 4: HFMEA Decision Tree
YES NO
71
Step 4: HFMEA Decision Tree
NO
YES
72
Step 4: HFMEA Decision Tree
YES
NO
STOP
73
Step 4: HFMEA Decision Tree
NO
STOP
PROCEED
74
HFMEA PSA Example
Step 4B,C, D. Determine hazard score and list all the potential
causes for each potential failure mode.
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalysis
Responsible
Management
Concurrence
Existing Control
Person
Detectability
Single Point
Action
Haz Score
Probability
Weakness?
Measure ?
FailureMode: Type
Proceed?
Severity
FirstEvaluatefailure (Control,
modebefore Accept,
determiningpotential Eliminat ActionsorRationale
causes PotentialCauses e) forStopping OutcomeMeasure
Occasional
3F(1 Computer
Major
) Crash
----
9 N N Y
-->
1)a virusprocection f
---- software IRM
9 N N Y
-->
Remote
1)b t programtoreplace
--- existingequipment
2 Y Y --- N
>
75
HFMEA PSA Example
ReportResult-3F
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalysis
Responsible
Management
Concurrence
Existing Control
Person
Detectability
Single Point
Action
Weakness?
Haz Score
Probability
Measure ?
Proceed?
FailureMode: Type
Severity
FirstEvaluatefailure (Control,
modebefore Accept,
determiningpotential Eliminate ActionsorRationale
causes PotentialCauses ) forStopping OutcomeMeasure
Moderate
frequent
3F(5 Techmis-
) readsresults
-----
8 N N Y
->
frequent
)a continuousshiftwill
----- ---- notperformthistask
8 Y N
-> -->
frequent
)b PAL
----- MS
8 N N Y
->
remote
)c fadedbulbis
---- dectectable
2 N Y N
-->
frequent
76
Healthcare FMEA Process
Let’s work on another example that takes place in a healthcare
setting using the Healthcare FMEA Process…
77
HFMEA BCMA Example
78
HFMEA BCMA Example
79
HFMEA BCMA Example
80
HFMEA BCMA Example
Steps 3D. Identify all sub-processes under each
block. Consecutively letter these sub-steps.
Log Scan
onto Get med Scan patient Give
laptop cart meds band med
Update
record
83
HFMEA BCMA Example
Step 4. Hazard Analysis: List potential failure modes
for each process step.
Log
onto Get med Scan
laptop cart meds
84
HFMEA BCMA Example
Step 4. Hazard Analysis: List potential failure modes
for each process step.
Scan
patient Give Update
band med record
85
HFMEA BCMA Example
Step 4. Hazard Analysis: List potential failure modes
for each process step.
Log
onto Get med Scan
laptop cart meds
86
HFMEA BCMA Example
Step 4. List all the potential causes for each potential failure mode.
LogontoLaptop-4A
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalysis
Responsible
Management
Existing Control
Concurrence
Action
Person
FailureMode: Type
Detectability
Single Point
Weakness?
Haz Score
Probability
(Contro
Measure ?
FirstEvaluatefailure
Proceed?
modebefore Severity l,
determiningpotentia Accept, ActionsorRational
l PotentialCause Elimina e OutcomeMeasur
causes s te) forStopping e
4A( Laptop
Occasional
Moderate
1) unavailabl
e 6 Y N N Y
1)a lessthanorequalto ef
15minutes IR
6 Y N N Y M
15minutes IR
6 Y N N Y M
87
HFMEA BCMA Example
Step 4. List all the potential causes for each potential failure mode.
LogontoLaptop-4A
HFMEAStep4-HazardAnalysis HFMEAStep5-IdentifyActionsandOutcomes
Scoring DecisionTreeAnalysis
Responsible
Management
Concurrence
Existing Control
FailureMode: Action
Person
Type
Detectability
Single Point
FirstEvaluatefailur
Weakness?
Haz Score
Probability
(Contro
Measure ?
e
Proceed?
modebefore Severity l,
determiningpotenti Accept, ActionsorRational
al PotentialCause Elimina e OutcomeMeasur
causes s te) forStopping e
4A( Nopower
Occasional
Moderate
2)
6 Y N N Y
2)a re lessthanorequalto ef
15minutes IR
6 Y N N Y M
2)b chargedup s ef
EN
6 Y N N Y G
88
Summarize Today’s Discussion
89