2004 OPEN FORUM Abstracts
FAILURE MODE EFFECT ANALYSIS TO IMPROVE PATIENT SAFETY OF AN AEROSOL SET-UP BY NONRESPIRATORY PERSONNEL
Joseph, RRT-NPS, Jack Mullany, RRT-NPS,
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.