2004 OPEN FORUM Abstracts
FAILURE MODE EFFECT ANALYSIS TO IMPROVE PATIENT SAFETY OF AN AEROSOL SET-UP BY NONRESPIRATORY PERSONNEL
Christina
Joseph, RRT-NPS, Jack Mullany, RRT-NPS,
Pulmonary
Services, Sharp Mary Birch Hospital for Women, San Diego, CA.
Background: One of the first of only 17 freestanding women's hospitals
in the nation, Sharp Mary Birch Hospital for Women (SMBHW) provides
a full range of women's health care services that cover every stage
of a woman's life. While SMBHW is renowned for caring for expectant
mothers and delivering babies, there is much more to the hospital
than obstetrics. It is a six-story hospital with a 61 bed Level III
Neonatal Intensive Care Unit (NICU). The RCPs staff the NICU seven
days a week, 24 hours a day, and provide service to adult patients in
the 105-licensed medical, surgical and obstetrical bed facility.
Joint Commission on Accreditation of Healthcare Organization (JCAHO)
requires a Failure Mode Effects Analysis (FMEA) as part of assessing
patient safety. FMEA is a proactive, systematic, multidisciplinary
team-based approach to error prevention. FMEA assumes everything will
fail, humans err frequently, and the cause of an error often is
beyond the individual's control. Patient safety has been identified
as a high priority with JCAHO. Aerosol equipment is available in the
hospital supply area and assembled in the PACU on an “as
needed”basis for intubated patients coming from the operating
room (OR). PACU RNs set up and place patients on aerosols for short
periods of time until extubation. RNs are taught how to set up the
necessary equipment during initial orientation, however, competency
validation was not mandated. No process was in place to alert staff
of potential problems.
Method: This FMEA process was utilized
to determine the potential failure modes and possible consequence of
each failure mode. The team assigned a severity rating (significance)
to each consequence using the FMEA rating of a 1-10 scale, with 10
being the most severe, an occurrence rating (likelihood) of each
contributory factor with 10 being most certain to occur, and a
detection effectiveness rating with 10 being a lack of detection
control. The three ratings were multiplied (Severity x Occurrence x
Detection) to achieve a risk priority number and any risk greater
than 80 was addressed first. Development of a multidisciplinary
action plan was initiated to address how the contributory factors
would be rendered.
Results: The FMEA identified three areas
with the highest risk priority (RP). 1) RN not competent in the
aerosol set up (RP 500), 2) Apparent dead zones in the NICU where the
RCP was unable to receive a page from the PACU (RP 350), and 3)
Aerosol set up improperly (RP 200). An aerosol competency was
developed for RNs and is now an annual requirement. This competency
includes a staff visualization of gas flow with a physical assessment
of patient. A photo of the proper aerosol set-up is available on the
unit located by the supply cart. RCPs now pre-assemble the aerosol
set up and place in a set-up bag, minus the water. NICU RCPs are
always available as a resource for PACU personnel. A phone list was
developed in case the paging system failed.
Conclusion: There
are now initial and annual aerosol competency validations in place
for PACU RN’s to include hands-on return demonstration of
skill. The dedicated respiratory personnel for the NICU have expanded
to the PACU, to include supplying, stocking, and maintaining the
appropriate equipment and par level. They are also available to
support nursing staff with any additional needs. This ensures that
there is no breakdown in the equipment supply/demand process. We feel
confident that this proactive systematic approach will, indeed,
improve patient safety, related to aerosol set-ups by nonrespiratory
personnel.