Walking the Tightrope with a Safety Net

Session
Patient Safety and Quality

Authors
Robert Pierce
Director, Quality and Process Improvement
AnMed Health

Todd O'Quinn
Quality and Process Improvement
AnMed Health

Description
During this session, attendees will be able to learn how a community based hospital actually applied Failure Modes and Effects Analysis (FMEA) to a high risk, high volume process. In addition, attendees will learn about specific actions taken by the hospital to reduce potential risks in the blood transfusion process.

Abstract
An inseparable part of the Anderson community for nearly a century, AnMed Health has evolved into an impressive not-for-profit healthcare system. Anchored by Anderson Area Medical Center, the system and its 3,500 employees deliver health and medical services at more than 30 patient-care sites.

In the summer of 2003, a multidisciplinary team embarked on analyzing and evaluating the blood transfusion process through the use of a Failure Mode and Effects Analysis. The team felt that this quality improvement tool would help make a "safe" process, ?safer?. Annually, AnMed Health performs over 8,000 red blood cell transfusions. Because of the high volume and high risk involved with this process, our team took the time to examine how our process could potentially fail and developed specific preventive action plans to help reduce overall risk to our patients.

By examining the entire process, our team identified 30 potential failure modes and 39 causes associated with the potential failures. By evaluating each Risk Priority Number, the team elected to take action on three greatest potential failure modes. The actions taken have indeed improved our Blood Transfusion process, thereby making a once "safe" process a much "safer" process for our patients, physicians and staff members.