FMEA: 20/20 Foresight Deirdre, RN; Kim, RN Juliana; Marija Deirdre, RN; Kim, RN Juliana; Marija

FMEA 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

 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 procedure 2.Training or education 3.Environment 4.People 5.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 procedure 2.Training or education 3.Environment 4.People 5.Technology software or hardware change

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 ?? 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 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

Results  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?

Group Dynamics Wow, that was easy!

Fin