Failure mode effect analysis applied to hospital TB program

Abstract

ISSUE: In 2001 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) wrote a standard that requires healthcare organizations to conduct at least one failure mode effects analysis (FMEA) annually on a patient safety issue. The idea is to select a process that is thought to be working effectively. The FMEA is used to evaluate potential failure modes. PROJECT: This is a seven-campus hospital system. A multidisciplinary team was formed to perform an FMEA on the current TB program. The current process for identification and management of TB patients was flowcharted, as was the ideal process. Each step of the current process was then reviewed and evaluated for possible failure modes. Potential failures were then assigned a criticality score by members of the FMEA team. RESULTS: Eleven potential failure modes were identified. The failure mode that received the highest criticality score was ability to isolate. Of the seven campuses in the system, three of the emergency departments did not have airborne infection isolation (ABII) capacity. In addition, it was discovered that not all rooms thought to be suitable for ABII were. Nursing did not always activate alarms on ABII rooms or utilize portable high-efficiency particulate air (HEPA) filters correctly. Failure to screen, and thereby identify, potential TB patients was identified as the next most critical potential failure. A flaw was found in the current screening tool—weight loss as a risk factor, had been left off of the TB assessment screen when computerized charting was implemented. In addition, there is always a risk that a screen may not consistently identify the conditions being screened, in this case potential active TB. In reviewing data, we found that in one-third of confirmed pulmonary TB cases there were exposures related to failure of healthcare workers to suspect TB and isolate. Other failure modes identified were employee knowledge of size and type of PFR-95 respirator, communication of ABII status to other departments, inefficient notification system to employees when an exposure had occurred, and appropriate reporting of PPD conversions in employees. LESSONS LEARNED: FMEA is an effective tool for healthcare facilities. By using a multidisciplinary team, failure modes can be effectively identified and corrective actions put into place that improve processes and outcomes.