1. PCA oversedation: application of Healthcare Failure Mode Effect (HFMEA) Analysis.
- Author
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Cronrath P, Lynch TW, Gilson LJ, Nishida C, Sembar MC, Spencer PJ, and West DF
- Subjects
- Drug Overdose, Humans, Organizational Case Studies, Patient Care Team, Risk Assessment, Washington, Analgesia, Patient-Controlled adverse effects, Analgesia, Patient-Controlled nursing, Analgesics, Opioid administration & dosage, Hydromorphone administration & dosage, Medication Errors prevention & control, Quality Assurance, Health Care, Safety Management
- Abstract
Hospital systems utilize many varied problem-solving processes to address system improvements and ensure patient safety. The Healthcare Failure Mode Effect Analysis (HFMEA) model is one of these tools and uses a multidisciplinary team to look at processes, diagramming the steps involved to identify potential failure points. The application of the HFMEA model allowed one large health care system to address a complex process by prioritizing proactive change improvements in order to prevent postoperative patient-controlled anesthesia oversedation events. The changes implemented identified 16 failure points with a hazard score of 16 or greater. One year later, the established system HFMEA goal was met: oversedation events were reduced by 50%.
- Published
- 2011