fmea: 20/20 foresight deirdre, rn; kim, rn juliana; marija deirdre, rn; kim, rn juliana; marija

FMEA: 20/20 ForesightFMEA: 20/20 Foresight

Deirdre, RN; Kim, RNJuliana; Marija

Deirdre, RN; Kim, RNJuliana; Marija

FMEA of Alaris Smart PumpFMEA of Alaris Smart Pump“Using Failure Mode and Effects Analysis to

Plan Implementation of Smart IV Pump Technology”

“Using Failure Mode and Effects Analysis to Plan Implementation of Smart IV Pump Technology”

IV medication errors are common

Failure Mode and Effects Analysis used to evaluate smart pump to reduce pump programming and med errors

Drug library programming capability with medication dosage limits

IV medication errors are common

Failure Mode and Effects Analysis used to evaluate smart pump to reduce pump programming and med errors

Drug library programming capability with medication dosage limits

Midwestern Academic Medical Center

Multidisciplinary committee assembled to evaluate

Committee identified 29 desired criteria

ALARIS pump met specifications

Midwestern Academic Medical Center

Multidisciplinary committee assembled to evaluate

Committee identified 29 desired criteria

ALARIS pump met specifications

HFMEA (Healthcare FMEA) model used

Team first looked for previous failures of new pump, found general satisfaction

Team then mapped medication-use process with old and new pumps

HFMEA (Healthcare FMEA) model used

Team first looked for previous failures of new pump, found general satisfaction

Team then mapped medication-use process with old and new pumps

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Hazard Analysis followed mapping Over 200 failure modes identified Assigned risk priority number or hazard score

All high hazard scores assigned action

1. Policy and procedure2. Training or education3. Environment4. People5. Technology software or hardware change

Hazard Analysis followed mapping Over 200 failure modes identified Assigned risk priority number or hazard score

All high hazard scores assigned action

1. Policy and procedure2. Training or education3. Environment4. People5. Technology software or hardware change

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FMEA Team Recommendations

FMEA Team Recommendations

Mandatory user training before use, hands-on training for nurses and anesthesiology

Short and long term software and hardware changes to address failure modes

Different drug profiles for different units (ICU, Med Surg, ED)

Anesthesia mode New pole system for transport (bigger pump)

Mandatory user training before use, hands-on training for nurses and anesthesiology

Short and long term software and hardware changes to address failure modes

Different drug profiles for different units (ICU, Med Surg, ED)

Anesthesia mode New pole system for transport (bigger pump)

?? Budget ???? Budget ??

No budget specifically mentioned. The

initial 22 member FMEA team included

members from central supply and

engineering that likely offered cost

analysis.

No budget specifically mentioned. The

initial 22 member FMEA team included

members from central supply and

engineering that likely offered cost

analysis.

Evaluation StrategiesEvaluation Strategies

Audits of pump programming Monitoring of user training Monitoring of IV medication administration event reports and complaints for 3 months post implementation

Patient resuscitation events observed for problems

Audits of pump programming Monitoring of user training Monitoring of IV medication administration event reports and complaints for 3 months post implementation

Patient resuscitation events observed for problems

ResultsResults Audit--Drug library used in 99.6% of medication infusions, 97% had correct unit profile

Event log data retrieved from new pumps—301 dosing alerts that led to reprogramming of infusion rate over 3 months

The FMEA process was useful in identifying potential smart IV pump implementation problems.

Continued monitoring for system failures and errors is necessary after implementation.

Audit--Drug library used in 99.6% of medication infusions, 97% had correct unit profile

Event log data retrieved from new pumps—301 dosing alerts that led to reprogramming of infusion rate over 3 months

The FMEA process was useful in identifying potential smart IV pump implementation problems.

Continued monitoring for system failures and errors is necessary after implementation.

Questions?Questions?

Group DynamicsGroup Dynamics

Wow, that was easy!

Fin

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