Proactive Risk Assessment of Blood Transfusion Process, in Pediatric Emergency, Using the Health Care Failure Mode and Effects Analysis (HFMEA)

Reza Dehnavieh,Ali Vafaee-Najar,Hossein Ebrahimipour,Hamid Esmailzdeh,Somayeh Noori Hekmat,Yasamin Molavi-Taleghani

doi:10.5539/gjhs.v7n1p322

Abstract

Introduction:Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, therefore this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology.Methodology:This cross-sectional study analyzed the failure mode and effects of blood transfusion process by a mixture of quantitative-qualitative method. The proactive HFMEA was used to identify and analyze the potential failures of the process. The information of the items in HFMEA forms was collected after obtaining a consensus of experts’ panel views via the interview and focus group discussion sessions.Results:The Number of 77 failure modes were identified for 24 sub-processes enlisted in 8 processes of blood transfusion. Totally 13 failure modes were identified as non-acceptable risk (a hazard score above 8) in the blood transfusion process and were transferred to the decision tree. Root causes of high risk modes were discussed in cause-effect meetings and were classified based on the UK national health system (NHS) approved classifications model. Action types were classified in the form of acceptance (11.6%), control (74.2%) and elimination (14.2%). Recommendations were placed in 7 categories using TRIZ (“Theory of Inventive Problem Solving.”)Conclusion:The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency.

Highlights

Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology
13 failure modes were identified as non-acceptable risk in the blood transfusion process and were transferred to the decision tree
The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency

Summary

Introduction

Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology. A risk management program in one of the hospitals in Melbourne, reduced the undesired events to hospitalized patients from 1.35% to 0.74% (61% decreases) and to emergency patients from 3.26% to 0.48% (78.2% decreases) (Wolff, Bourke, Campbell, & Leembruggen, 2001) Based on the Joint Commission on Accreditation of Health Care Organizations statistics, blood transfusion failures (2.9%) have been enlisted as the priority adverse events in all the US hospital wards including emergency wards, since 2008. Since 1990, different proactive risk management programs were introduced, following the infusion of “Systems Thinking” which considered optimizing the systems and work processes as the best way to reduce failures by humans that are fallible (Card, Ward & Clarkson, 2012) According to the VA National Center for Patients’ Safety and the American Joint Commission on Accreditation of Health Care Organizations, HFMEA is one of the most leading risk management programs (Derosier, Stalhandske, Bagian, & Nudell, 2002). By HFMEA approach, we can use a mechanism for categorizing the failure modes, identifying the root causes of failures and detecting the susceptible area in blood transfusion procedure for the purpose of increasing awareness of the staff and patients’ safety in this procedure. (Sorra et al, 2008)

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