Reducing errors during surgery using an improved Healthcare Failure Mode and Effect Analysis model

Abstract

Background/Aims Prospective risk management is a necessary measure when managing and providing the right response to a healthcare system error. This article provides an improved model of the Healthcare Failure Mode and Effect Analysis model, which aims to reduce errors in the operating room and improve on the major defects found in the Healthcare Failure Mode and Effect Analysis model. Methods The improved model presented in this descriptive mixed-methods article was examined in 2015 on selective processes in total knee replacement in Shahid Madani Hospital's operating rooms in Karaj, Iran. Data were collected through clinical observations, individual and group interviews, and collaborative conversations with the study team. Results A total of 8 activities and 15 modes of failure were identified in 5 selection processes in total knee replacement surgery. The identified modes of failure were given scores. Ultimately, 15 potential causes and 17 measures were proposed for 12 failures. The failure of the ‘unmanaged nurse or the anaesthesia technician in the operating rooms’ had the highest priority, and ‘chest leads’ and a ‘blood pressure cuff placed in the incorrect position’ had the lowest priority. Conclusion The improved model better reported the risk priorities of failures in 9 out of 12 modes. It was also able to resolve major defects in the Healthcare Failure Mode and Effect Analysis model and produce more reliable results.