Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: Evaluation of the sterilization and use of surgical instruments

被引:55
作者
Linkin, DR
Sausman, C
Santos, L
Lyons, C
Fox, C
Aumiller, L
Esterhai, J
Pittman, B
Lautenbach, E
机构
[1] Univ Penn, Div Infect Dis, Dept Med, Philadelphia, PA 19104 USA
[2] Univ Penn, Ctr Clin Epidemiol & Biostat, Philadelphia, PA 19104 USA
[3] Univ Penn, Ctr Educ & Res Therapeut, Philadelphia, PA 19104 USA
[4] Univ Penn, Dept Orthoped, Philadelphia, PA 19104 USA
[5] Univ Penn, Dept Biostat & Epidemiol, Philadelphia, PA 19104 USA
[6] Vet Adm Med Ctr, Philadelphia, PA 19104 USA
关键词
D O I
10.1086/433190
中图分类号
R392 [医学免疫学]; Q939.91 [免疫学];
学科分类号
100102 ;
摘要
Healthcare Failure Mode and Effects Analysis (HFMEA) is a methodology for correcting latent system errors before they lead to adverse events. We examined the utility of HFMEA in evaluating the sterilization and use of surgical instruments. First, a multidisciplinary team graphed the process in a flow diagram. A hazard analysis was then used to examine potential failure modes (i.e., ways in which a process can fail) and their causes and to score the severity and other factors for each failure mode cause. Actions were then planned to address the selected failure mode causes. Flow charts were created for 3 foci: sterilization process, reading of biologicals, and use of equipment. Information was gathered through interviews and a review of the literature. Multiple clinically significant system errors were identified, and actions to correct them were developed. The HFMEA methodology facilitated the detection of previously unrecognized system errors, demonstrating its potential utility in addressing healthcare epidemiology-related adverse events.
引用
收藏
页码:1014 / 1019
页数:6
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