Risk assessment of the emergency processes: Healthcare failure mode and effect analysis

doi:10.5847/wjem.j.1920-8642.2016.02.003

Abstract

Abstract:

BACKGROUND: Ensuring about the patient's safety is the first vital step in improving the quality of care and the emergency ward is known as a high-risk area in treatment health care. The present study was conducted to evaluate the selected risk processes of emergency surgery department of a treatment-educational Qaem center in Mashhad by using analysis method of the conditions and failure effects in health care.
METHODS: In this study, in combination (qualitative action research and quantitative cross-sectional), failure modes and effects of 5 high-risk procedures of the emergency surgery department were identified and analyzed according to Healthcare Failure Mode and Effects Analysis (HFMEA). To classify the failure modes from the "nursing errors in clinical management model (NECM)", the classification of the effective causes of error from "Eindhoven model" and determination of the strategies to improve from the "theory of solving problem by an inventive method" were used. To analyze the quantitative data of descriptive statistics (total points) and to analyze the qualitative data, content analysis and agreement of comments of the members were used.
RESULTS: In 5 selected processes by "voting method using rating", 23 steps, 61 sub-processes and 217 potential failure modes were identified by HFMEA. 25 (11.5%) failure modes as the high risk errors were detected and transferred to the decision tree. The most and the least failure modes were placed in the categories of care errors (54.7%) and knowledge and skill (9.5%), respectively. Also, 29.4% of preventive measures were in the category of human resource management strategy.
CONCLUSION: "Revision and re-engineering of processes", "continuous monitoring of the works", "preparation and revision of operating procedures and policies", "developing the criteria for evaluating the performance of the personnel", "designing a suitable educational content for needs of employee", "training patients", "reducing the workload and power shortage", "improving team communication" and "preventive management of equipment's" were on the agenda as the guidelines.

Key words: Emergency, Risk assessment, Healthcare failure mode

Yasamin Molavi Taleghani, Fatemeh Rezaei, Hojat Sheikhbardsiri. Risk assessment of the emergency processes: Healthcare failure mode and effect analysis[J]. World Journal of Emergency Medicine, 2016, 7(2): 97-105.

Figures/Tables 5

Table 1

Table 2

Distribution of failure modes in each area of the error scoring matrix and classification of failure modes based on the model of management association of nursing error for the selected emergency surgery processes

High-risk processes of emergency surgery	Number of sub-processes	Number of failure modes	Number of intervention levels categories				Frequency percentage of failure modes based on association model of "management of nursing error"
High-risk processes of emergency surgery	Number of sub-processes	Number of failure modes	Emergency levels	Urgent levels	Programing levels	Monitoring levels	Care process errors	Communication errors	Administrative process errors	Knowledge and skill errors
Care and patients nursing
Ordered by physician	2	9	0	0	8	1	7	4	3	0
Checking and importing of illegible prescriptions by nurse patient	2	5	0	0	5	0	5	0	2	2
Executing the physician's commands and nursing records	2	16	0	0	16	0	11	4	3	2
Collection and delivery of patients records to the secretory	1	4	0	0	2	2	3	1	1	0
First visit of the patient
Filing in the ward	1	4	0	0	3	1	4	0	1	0
History taken by the intern and examination by the resident	5	19	0	0	18	1	13	8	7	1
Doing the tests and required graphs	1	4	0	0	4	0	4	1	1	1
Checking and implementation of physician's commands	3	9	0	0	7	2	8	4	9	2
Patient radiology
Request for radiology	2	8	0	2	5	1	5	2	0	1
Request a graph with surgical emergency admission	2	6	0	0	6	0	1	2	2	2
Request a graph from the ward to the radiology unit	3	6	0	0	6	0	2	3	2	0
Transfer patients to the radiology unit	1	7	0	5	2	0	8	0	1	0
Doing radiology	1	4	0	0	2	2	4	0	1	0
Get answers and report	2	5	0	0	5	0	5	0	1	1
Laboratory management
Request for the laboratory test	6	19	0	4	14	1	17	7	0	1
Collecting and sending samples	4	16	0	3	13	0	13	2	5	4
Sample analysis	4	15	0	3	12	0	14	0	6	1
Laboratory test result issue	1	4	0	3	1	0	4	0	2	2
Report to the related physician	2	5	0	1	4	0	4	0	0	1
Outpatient admission
Accepting patient in triage	4	15	0	4	11	0	15	6	1	0
Patient transfer to the emergency surgery	2	7	0	0	7	0	7	3	0	0
Central reception and temporary early filing of hospitalization	4	14	0	0	3	11	14	4	0	0
Patient admission in the ED surgery	3	7	0	0	3	4	6	1	1	0
Total score	61	217	0	25	166	26	181	54	53	21

Table 2

Table 3

Table 4

The worksheet of failure modes techniques and HFMEA for some high-risk failure modes of the selected emergency surgery processes

Hazard analysis									Action and outcome measures
Failure mode	Potential causes	Scoring			Decision tree analysis			Proceed?	Action type	Actions or rate for stopping
Failure mode	Potential causes	Severity	Occu-rrence	Hazard score	Weakness point	Existing control measures	Detecta-bility	Proceed?	Action type	Actions or rate for stopping
Recording the incorrect information in triage sheet	→	3	3	9	→	No	No	Yes
	1) Giving false information from the patient or not having knowledgeable person	3	3	9	→	No	No	Yes	C	1) Assessing the patient's ability to communicate effectively with healthcare providing; 2) Detailed examination of the patient and not limited to what patient said
	2) Lack of a correct communication of physician with patient	3	2	6	→	No	No	Yes	C	1) Assessing the patient's ability to communicate effectively with healthcare providing; 2) Developing the criteria of performance evaluation and monitoring clinical process; 3)Training course of effective communication and respect to the rights of service recipients
	3) Lack of confidence of the patient and patient's caregiver to the nurse	3	3	9	→	No	Yes	No	C	1) Assessing the ability of patient to communicate effectively with healthcare provider; 2) Catches the patient's desire for giving information; 3) Implementation of the ethics nursing codes in the hospital for better interaction with the patient
Error in patient transfer to the emergency surgery (incorrect refer of patient)	→	3	3	9	→	No	No	Yes
	1) Incorrect decision by physician	3	2	6	→	No	No	Yes	C	1) Correct communication with patient; 2) Detailed examination and complete knowledge of the patient's clinical condition; 3) Correct history taking from the patient; 4) Taking into account the advice of other clinicians by the service provider if necessary
	2) Lack of a good protocol to determine the correct situation of patient	3	3	9	→	No	Yes	No	C	1) Assessing the patient's ability to communicate effectively with healthcare provider; 2) Detailed examination of the patient and not limited to what patient said
Delay to refer patient to the radiology	→	3	3	9	→	No	No	Yes
	1) Absence of nurse aid or the intern	3	3	9	→	No	Yes	No	C	1) Coordination in medical team; 2) Sharing information in medical team; 3) Responsibility about patient safety
	2) Lack of cooperation of patient and being unstable of the patient	3	4	12	→	No	No	Yes	C	1) Cooperation for receiving information and consequences of each method; 2) Awareness of patient about the need to do radiology; 3) Monitoring the work process; 4) To pass information sharing between the medical team
	3) Lack of cooperation, coordination and team problems between radiology and emergency surgery	3	3	9	→	No	No	Yes	C	1) Sharing the information between medical team; 2) Training courses of team work; 3) Continuous monitoring of doing process; 4) Coordinated acting of medical team
	4) Overcrowding in radiology and or emergency surgery	3	3	9	→	No	Yes	No	C	1) Supply of additional power; 2) Fitting the work volume with number of human resources; 3) Coordination of medical team and establishment of stress management; 4) Determination of standard range and keeping client data in the standard range; 5) Coordination between radiology and surgery wards
Unnecessary graph for patient is requested by the physician	→	3	3	9	→	No	No	Yes
	1) Lack of correct communication of physician with the patient	3	2	6	→	No	No	Yes	C	1) Assessing the patient's ability to communicate effectively with healthcare provider; 2) Developing criteria of performance evaluation and monitoring the clinical process; 3) Training course of effective communication and respect to the rights of service recipients
	2) Lack of knowledge and enough skill by physician	3	2	6	→	No	No	Yes	C	1) Encourage physicians to ask about the ambiguity (taking into account the comments of other experts); 2) Periodic training for clinical staff
Delay in the beginning of the test on the intended sample in laboratory	→	3	4	12	→	No	No	Yes
	1) Overcrowding of the laboratory	3	4	12	→	No	Yes	No	C	1) Reducing the workload and arranging the tables of work shifts and avoid of row shifts; 2) Supply of additional power; 3) Fit the work volume with the number of human resources; 4) Coordination of medical team and establishment of stress management
	2) Lack of awareness of the importance of the subject	3	3	9	→	No	No	Yes	C	1) Performing a justification course at the beginning; 2) Determination a leader or supervisor for the team; 3) Sharing information with medical team; 4) Continuous monitoring of healthcare providing
	3) Lack of monitoring of a technical responsible on the process of doing work	3	3	9	→	No	No	Yes	C	1) Periodic monitoring and evaluation of laboratory; 2) Checking the competence of the team leader and responsible person; 3) Continuous monitoring of doing processes
Failure (error) in entering test answer in the system through laboratory	→	3	3	9	→	No	No	Yes	C
	1) High work volume and staff fatigue	3	4	12	→	No	No	Yes	C	1) Programing and management of actions during the shift; 2) Work division; 3) Setting shift tables and lack of giving ling shifts
	2) Lack of enough experience	3	2	6	→	No	No	Yes	C	1) Evaluation and control of activity and checking the final test answers by technical manager; 2) Developing the careers of introduction of new entrants personnel to the ward's criteria

Table 4

Table 5

Classification of strategies and preventive measures for causes of high-risk error modes (risk score ≥8)

Strategy classification	Improvement strategy by means of the TRIZ method	Patient radiology	Laboratory manage-ment	Outpatient admission	Total
Human resources management	Determination a supervisor for treatment team, evaluation the competency of team leader, conducting periodical assessment and offering feedback to the personnel, Inform treatment team by necessary information, defining the responsibilities and announcing them, reducing the work load and correcting the lack of work forces, continuous supervision and controlling the performance procedures and adjusting the workload with staff.	17	44	7	68
Installation of electronic prescribing system	Implementation procedure on drug combination.	0	1	0	1
Making people accountable to patient's safety	Readable information in patients clinical documents, all reports must have stamp, signature, date and time, culturally appropriate environment for patient safety and deployment an incident reporting system, encouraging the staff to ask question in case of obscurity and resolving the issue of lack of man power, detachment and pursuing the test results in form of root analysis of the events and reporting the critical results.	3	7	2	12
Medical equipment management and process standardization	Regular calibration of medical equipment, emergency service of medical equipment and devices, checklists for maintenance of the tools and facility management, purchasing of protective equipment, creating a qualitative committee and monthly views of the equipment of radiology unit.	6	8	3	17
Improvement of patient identification process	Applying key identifiers in patient identification, improvement of the patient's recognition processes and revising the guidelines for the correct recognition of the patients.	0	6	0	6
Making clear and transparent policies and procedures	The re-engineering of the process, preparing and organizing the executive guidelines and protocols, preparing new forms with special parts, facilitating the processes and removing the unnecessary steps, designing a special check-list for evaluation of the patient's transition between emergency and radiology units, revision policies, simplifying the process and eliminating unnecessary steps and audits process.	5	9	6	20
Making sure about availability of suitable technology for quality improvement	Fundamental improving of the software for entering the physician's commands for tests.	0	3	1	4
Continuous training and briefing care providers at the beginning of employment	Re-training courses and preparing proper training content according to the needs of the personnel, the scientific training for prescription writing and continuous medical training for the physicians, training of recommendation and instructions, continuing the re-training programs for physicians, training of recommendation and instructions.	7	16	3	26
Participating patients in treatment process	His/her accompanying person and teaching all the regulations of the sector and offering the sufficient data and patient's training, patient's contribution by making effective relationship with them, development of educational patients.	5	1	7	13
Implementing and monitoring suitable changes in clinical processes based on analysis of reliable data	Continuous supervision, defining the periodical performance assessment criteria and providing feedback to the personnel, introducing a reference laboratory and performing some of the important tests randomly in various periods as binary tests by the hospital laboratory and the reference lab, monitoring on following up standards.	7	13	2	22
Promotion of communication amongst treatment team members	Don't use of abbreviations, accurate documentation of all oral (telephone) orders, complete registration of the data, obeying the oral commands only in urgent cases.	0	2	3	5
Team work	Coordination of treatment team, holding teamwork training courses, improvement of the inter-sectorial relations and the supervision of the person responsible for the shift on the work in sectors, improving the team relations.	13	22	2	37
Total		63	132	36	231

Table 5

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Intervention level	Probability	Catastrophic (4)	Important (3)	Intermediate (2)	Minor (1)
Emergency	Usual (4)	16	12	8	4
Urgent	Sometimes (3)	12	9	6	3
Programming	Unusual (2)	8	6	4	2
Monitoring	Rare (1)	4	3	2	1

Error cause	Care and patients nursing	First visit of the patient	Laboratory management	Outpatient admission	Patient radiology	Total
Technical
External	0	0	0	0	0	0
Design	0	0	0	0	1	1
Structure	0	0	2	2	1	5
Material	0	0	3	0	1	4
Organizational
External	0	0	6	1	4	11
Transfer of knowledge	0	0	2	2	2	6
Protocols	0	0	1	1	2	4
Priorities management	0	0	1	0	1	2
Culture	0	0	3	0	0	3
Human factors
External	0	0	6	0	1	7
Knowledge based	0	0	3	0	2	5
Competence	0	0	1	0	0	1
Cooperation	0	0	3	0	3	6
Evaluation	0	0	0	1	0	1
Action	0	0	1	0	0	1
Monitoring	0	0	4	0	0	4
Slips	0	0	3	1	2	6
Falling	0	0	0	0	0	0
Other factors
Related to patients	0	0	0	3	2	5
Unclassified factors	0	0	1	1	0	2
Total	0	0	40	12	22	74

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