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Colombian Journal of Anestesiology

Print version ISSN 0120-3347

Abstract

VAZQUEZ-VALENCIA, Agustín et al. Usefulness of failure mode and effects analysis for improving mobilization safety in critically ill patients. Rev. colomb. anestesiol. [online]. 2018, vol.46, n.1, pp.3-10. ISSN 0120-3347.  https://doi.org/10.1097/cj9.0000000000000002.

Introduction:

Patient safety has become a core value in health organizations, requiring the use of significant resources in order to avoid accidents during hospital stay. Health care can create risks, and patient safety is the most important objective in care quality. Failure Mode and Effects Analysis (FMEA) is a preventive tool that helps anticipate potential errors and adverse events, setting up barriers to prevent them from happening, or mitigating their effects or, in the event they do happen, mitigating their impact on the most vulnerable link in health care, namely, the patient.

Objectives:

To analyze, using the FMEA tool, mobilization of intubated critical ill patients in the Intensive Care Unit.

Method:

A brainstorming session was held within the service to identify the most frequent potential errors in the process. Subsequently, the FMEA method with its different phases was applied, prioritizing risk according to the RPN (Risk Priority Number) index and selecting improvement actions for those with an RPN greater than 300.

Results:

The result was the identification of 101 failure modes, of which 46 exceeded the RPN of 300. As a result of this work, 63 improvement actions have been proposed for those failure modes with NPR scores above 300.

Conclusion:

The conclusion of the study is that FMEA was a useful tool for anticipating potential failures in the process and proposing improvement actions for those that exceeded an RPN of 300.

Keywords : Intubation; Intratracheal; Patient Safety; Intensive Care Units; Healthcare Failure Mode and Effect Analysis; Risk Management.

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