The purpose of this presentation is to describe how two robust process improvement tools can be used to promote highly reliable error reduction in a complex hospital environment.
An effective RCA and FMEA is a key feature of a highly reliable organization’s robust process improvement program. The RCA at its most effective considers system issues as causes and human errors as effects, considers and mitigates for sources of bias in the investigation , creates strong actionable, timed interventions that address the root causes found and is supported by the highest levels of organizational leadership (National Patient Safety Foundation, 2015). The RCA is generally used to analyze an event or a close call that has been identified. An FMEA, on the other hand, is used to predict and identify safety or problematic gaps in a process before an event occurs. Both methods if not intentionally facilitated can have challenges to high reliability such as bias, failure to consider system issues, failure to encourage diverse opinions in the process, choosing interventions which do not consider human factors and failure to monitor and sustain the improvement. When used effectively, the tools are a key component of a highly reliably organization, leading to sustainable improvement.
Implementing the robust improvement tools, RCA and FMEA, through the lens of high reliability principles has led to an increase in staff perception of patient safety and how the organization reacts to and prevents adverse events. Improvement in the AHRQ Hospital Survey on Patient Safety was realized in the items of "organizational learning from erro"r and "non-punitive response to error". One RCA led to a system change of the counting process in the operating room that identifies a mandatory time out for counting prior to close. After implementation, there have been no further retained foreign objects over the last year. An FMEA at the same facility identified at least 20 high risk opportunities for failure in a pediatric resuscitation event. Mitigation strategies have been implemented for all opportunities and currently, the process was tested with no deficiencies.
Implications for Nursing Practice
High reliability is dependent upon identifying conditions for adverse events before they occur and creating resilience in the system for staff to react to safety issues before harm to a patient occurs. The RCA and FMEA are tools which promote both anticipation and mitigation and can serve as boundary spanning processes, linking process improvement to high reliability.
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