Saturday, November 3, 2007

This presentation is part of : Promotion of Quality of Care
Failure Mode Effect Analysis Team Facilitator: A Novel Leadership Role for the APN to Improve Chemotherapy Safety
Norma Ann Sheridan-Leos, RN, MSN, AOCN, CPHQ, Clinical Quality Improvement, M. D. Anderson Cancer Center, Houston, TX, USA
Learning Objective #1: define the term FMEA.
Learning Objective #2: state the five steps used in the FMEA process.

Significance: Failure Mode Effect Analysis (FMEA) is a proactive risk management assessment technique that has been successfully used in the non-healthcare industry to prevent errors from occurring in equipment design and processes. Chemotherapy used in the treatment of cancer, is associated with serious and potentially life threatening side effects, and has a high risk of causing significant patient harm when an error occurs.  Throughout the chemotherapy process, from prescribing to patient monitoring, there is a high risk for life threatening errors to occur. Because Advance Practice Nurses (APNs) have many responsibilities in the chemotherapy process and advanced education, they are in a unique position to lead and facilitate groups to improve the chemotherapy process.

Interventions: The APN Facilitator used a variation of the FMEA process developed by manufacturing industry. Using this process all of the steps involved in chemotherapy were studied, failure modes were identified, risk analysis and prioritization of risk were completed. Then risk reduction techniques were used to proactively improve the chemotherapy process.

Evaluation:  FMEA is useful in identifying potential errors that nurses and other healthcare team members may not realize exist at the organization. Although conducting a FMEA can not ensure that the chemotherapy process will be “fail-safe,” FMEA participants felt strongly that the FMEA process has;

Reduced the likelihood of errors occurring, helped them feel more confident in the chemotherapy process, improved understanding of the chemotherapy process, and improved the working relationship with other members of the chemotherapy team