Using Health Care Failure Mode and Effect Analysis™: The VA National Center for Patient Safety’s Prospective Risk Analysis System

Abstract

Background

Most patient safety reporting systems concentrate on analyzing adverse events; injury has already occurred before any learning takes place. More progressive systems also concentrate on analyzing close calls, which affords the opportunity to learn from an event that did not result in a tragic outcome. Systems also exist that permit proactive evaluation of vulnerabilities before close calls occur. The engineering community has used the Failure Mode and Effect Analysis (FMEA) technique to accomplish this function, and the Department of Veterans Affairs (VA) National Center for Patient Safety has developed a hybrid prospective risk analysis system, Health Care Failure Mode and Effect Analysis (HFMEA™).

Key aspects of the HFMEA™ process

HFMEA™ is a 5-step process that uses an interdisciplinary team to proactively evaluate a health care process. The team uses process flow diagramming, a Hazard Scoring Matrix™, and the HFMEA Decision Tree™ to identify and assess potential vulnerabilities. The HFMEA™ Worksheet is used to record the team’s assessment, proposed actions, and outcome measures. HFMEA™ includes testing to ensure that the system functions effectively and new vulnerabilities have not been introduced elsewhere in the system.

The VA rollout

HFMEA™ was successfully introduced to the VA system through a series of video-conferences in August 2001. These broadcasts included a prepared training video and interactive question-and-answer sessions. To ensure a successful first year of the program, all VA facilities will focus on the same topic, with support materials from the NCPS office; the topic is a review of the contingency system for distribution of medications in the event of failure of the bar code medication administration process.