2007 OPEN FORUM Abstracts
C. Agard1, D. Burns1, E. Huey1, C. Kamikawa1, S. Kaya1
JCAHO requires that “an ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients is defined and implemented.” Our hospital identified a house-wide oxygen outage as a potentially high risk event and performed a failure mode and effect analysis (FMEA) to mitigate the risks of such a failure. Key questions that provided the stimulus for the team were: Do staff know what to do in the event of house-wide oxygen failure? How will patient safety be protected?
The questions were addressed through an FMEA, which is a proactive response to an area of concern. The assessment included an evaluation of the risk of failure with a 10-step process to determine potential failure modes and possible consequences of each failure mode. The process helped to identify, evaluate and rank potential failure modes and prioritize high risk areas for action. A survey of patient care staff was done to assess staff preparedness in ensuring patient safety.
The FMEA identified four high risk areas and an action plan was implemented to address these failure risks:
1: Staff response to oxygen alarms is inadequate. Response was new signage on all oxygen alarms directing the appropriate response.
2: In the event of a hospital-wide failure, we may be unable to meet patient needs with current equipment. Response was to acquire additional regulators. Since the survey showed that staff was often not aware of E-cylinder duration, quick reference “stop lights” were attached to all oxygen cylinders.
3: All hospital staff would not know how to respond to an outage. Response was to develop a comprehensive plan to address multiple oxygen outage scenarios, both short and long term, at the hospital and community level, which was addressed in collaboration with the local community resources. The new plan was incorporated into the hospital’s safety competencies and the Emergency Preparedness Manual.
4: Dependence on an outside provider increased risk. Response was to add a second oxygen supply tank on the campus.
The FMEA model provides a systematic approach to successfully address potential hospital wide system issues, to reduce the risk of failure, and to support improved patient safety. Team collaboration is invaluable in identifying and mitigating risks related to a hospital oxygen delivery system failure.