Professional Documents
Culture Documents
Reconciliation Process
Presented to
[Date]
By
[Insert Name]
Presentation Overview
• Introduction to Failure Mode and Effects Analysis (FMEA) and Its
Utilization In Healthcare
• Application of FMEA to a Medication Reconciliation Process
Upon Admission to the Hopsital
• Pilot Data Collection
• Lessons Learned / Closing Comments
• Questions and Discussion
Introduction to Failure Mode and Effects
Analysis (FMEA) and Its Utilization In
Healthcare
What is FMEA?
• This method, used by other high-risk industries, is defined as follows:
From “Potential Failure Mode and Effects Analysis (FMEA)” 3rd Edition. Reference manual developed by the FMEA teams at
Chrysler, Ford and General Motors working under the auspices of the Automotive Division of the American Society for Quality
Control (ASQC) and the Automotive Industry Action Group (AIAG)
Why Utilize FMEA in Healthcare?
• The Risk Priority Number (RPN) can be determined by the following equation:
– Severity Rank (S) x Occurrence Rank (O) x Detection Rank (D) = RPN
• The RPN directs the team to areas of greatest potential for harm. Recommendations
for corrective actions can be developed and prioritized based on results.
Application of FMEA to a Medication
Reconciliation Process Upon Hospital
Admission
Failure Modes Identified
The process of medication reconciliation upon admission is time-consuming. Obtaining staff buy-in to incorporate a new process into
• workflow design can be challenging
The FMEA process promotes positive cultural change within the organization
•
Resources
• Failure Mode and Effects Analysis (FMEA):
– Stoll, HW. Product Design Methods and Practices. New York: Marcel Dekker, Inc., 1999.
– From “Potential Failure Mode and Effects Analysis (FMEA)” 3rd Edition. Reference manual
developed by the FMEA teams at Chrysler, Ford and General Motors working under the auspices
of the Automotive Division of the American Society for Quality Control (ASQC) and the
Automotive Industry Action Group (AIAG)
– Strategies and Tips for Maximizing Failure Mode and Effect Analysis in your Organization.
White Paper prepared by the American Society for Healthcare Risk Management, July 2002.
Available at: http://www.hospitalconnect.com/ashrm/resources/files/FMEAwhitepaper.pdf.
Accessed December 6, 2002.
– Burgmeier, J. Failure Mode and Effect Analysis: An Application in Reducing Risk in Blood
Transfusion. Journal on Quality Improvement. 2002; 28:331-339.
– DeRosier, J et al. Using Health Care Failure Mode and Effect AnalysisTM: The VA National
Center for Patient Safety’s Prospective Risk Analysis System. Journal on Quality Improvement.
2002; 28:248-267.
Questions and Discussion