Aims and objectives
HFMEA (Healthcare failure modes and effects analysis) is a tool developed in 2002 and used to identify,
estimate and reduce risks for patients in a proactive way.[1]This method is highly recommended to improve patient safety and decrease the possibility to err for processes with inner complexity,
due to multidisciplinary approach or to the use of specific technologies,
like breast cancer radiotherapy.[2] To assess the impact of errors in our setting and plan interventions,
we decided to evaluate this pathway through HFMEA tool,
following the “step...
Methods and materials
A multidisciplinary and multi-professional teamwork reviewed in detail all the activities included in the patient pathway,
from the acceptance of the patient in Radiotherapy Unit to the end of therapy,
excluding intra-operative radiotherapy (IORT) because of its peculiarity.[3]For each activity,
the potential failure modes (PFMs) were figured out and assessed through a Risk Priority Number (RPN).
According to literature,
RPN results from the product of three different aspects: severity,
probability of occurrence and detectability.[4]Wedecided to adapt the grid proposed by Duwe et al.with values ranging...
Results
Eight main phases (patient acceptance,
chemotherapy,
simulation,
evaluation in Health Physics,
development of treatment plan,
treatment,
end of therapy),
98 activities and 143 PFMs were identified.As Figure 1 shows,
three different hospital units,
depicted in different colours,
are involved in the pathway: Radiotherapy (in blue),
Oncology (in green) and Health Physics (in orange).
The RPN values,
assigned for every PFM,
ranged from a minimum score of 1 to a maximum of 60.
We calculated mode (12),
median (12) as central tendency indexes and interquartile range...
Conclusion
HFMEA methodology,
supported by other techniques for quality improvements (e.g.
Root Cause Analysis,
Incident Reporting System),
was useful to identify critical aspects and prioritize interventions in breast cancer radiotherapy in accordance among professionals and it might be adapted for other healthcare organizations.
Nevertheless,
HFMEA methodology is a never ending analysis and it will be constantly monitored and updated.
Acknowledgments
The authors are pleased to acknowledge allHFMEA team members (Pierfrancesco Tricarco,
Giovanni Cattani,
Claudio Battistella,
Daniela De Corti,
Stefania Degan,
Alessandra Bin and Matteo Duratti) for...
Personal information
Department of Medical and Biological Science,
University of Udine,
Italy.
AcademicHospital of Udine,
Italy.
References
DeRosier J,
Stalhandske E,
Bagian JP,
Nudell T.
Using health care failure mode and effect analysis™: the VA National Center for Patient Safety's prospective risk analysis system.
The Joint Commission Journal on Quality and Patient Safety.
2002 May 1;28(5):248-67.
Chatman IJ.
Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction,
3^edition,U.S.A.,
Joint Commission Resources; 2010.
Ciocca M,
Cantone MC,
Veronese I,
Cattani F,
Pedroli G,
Molinelli S,
Vitolo V,
Orecchia R.
Application of failure mode and effects analysis to intraoperative radiation therapy using...