Verification of Correct Patient, Procedure, and Site at Governor Juan F. Luis Hospital and Medical Center

The Failure Mode and Effect Analysis

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One of the new National Patient Safety Goals per the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Standards is verifying the correct patient, procedure, and procedure site when performing an invasive procedure. With extensive research of this standard, we discovered that not only is the standard required within an operating suite, but also a cardiovascular and/or catheterization suite, and any other department where a patient under goes an invasive procedure. While preparing for our most recent survey (June 2004) by the Joint Commission, the Governor Juan F. Luis Hospital formed a committee called the Surgical Failure Mode and Effect Analysis (F.M.E.A.) committee to assess the failure processes of potentially performing a cardiac cath on the wrong patient. We followed the guidelines provided by JCAHO regarding the FMEA process and analyzed the potential failure modes that occurred in our previous scheduling, admitting, and performance of cath procedures. Unbeknownst to us within the cath lab and FMEA committee, were several failure modes that could have potentially caused the wrong patient to be scheduled in the cath lab. Fortunately, all the patients that were to be scheduled for procedures were done and no one was cathed that was not supposed to be cathed. Once we identified the potential failures, a resolution was developed by the committee and a new process was put into place to prevent any future failures from occuring. Our committee used Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction (Ed. Joint Commission Resources, December 2002) as a resource for our presentation. To date, the redesigned process has been followed by all physicians and hospital staff without any difficulties. In this presentation, the definition of FMEA is explained as well as the the path we took to identify and redesign our processes.

The Surgical FMEA Committee

Darice Plaskett RN, MS (Chief Operating Officer and Vice President of Patient Care services/Team Chair F.M.E.A. committee)

Jill Price RN, Head Nurse Cath Lab/Cardiology (Co-Chair F.M.E.A. committee & presentation submitter)

Wilhelmina Crawford RN Assistant Head Nurse Operating Room

Amie Bannis RNM Head Nurse Labor and Delivery

Dr. Cheryl Wade Chief of Surgery

Kathleen Ozelia Lewis RN MPH Infection Control Coordinator

Lydia Thomas RN MS Director of Risk Management

Colin McCammon MPA Safety Officer

Marion Wilson LPN Performance Improvement Nurse

Legend (for excel charts - see PDF available for download at red icon beneath author byline) Criticality analysis is a technique for prioritizing failure modes. Criticality index is the total sum of the severity, frequency, and detectability. Severity is the degree of seriousness of the injury that could ultimately result from the effect. Frequency is the likelihood that something will happen. Detectability is the degree to which something can be detected.