Failure mode and effect analysis in anesthesia medication errors

Hossam I. Eldesuky¹, Khaled M. Maghawry^2
1 Department of Anesthesia, Faculty of Medicine, Zagazig University, Zagazig, Egypt
² Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Correspondence Address:
Khaled M. Maghawry
MD, Department of Anesthesia, Faculty of Medicine, Ain Shams University, P.O. Box 11331, Cairo
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.7123/01.ASJA.0000423105.11453.64

Failure mode and effect analysis (FMEA) is a process in operation management for analysis of the potential failures within a system, and it can be used in healthcare to detect any errors and can find the action plans to prevent errors or risks. The aim of this study was to evaluate whether the FMEA is a useful method to predict anesthesia medication errors, identify those errors and analyze the root causes of failures, and how it can eliminate the risk.

A prospective study was carried out by a multidisciplinary team under the supervision of an anesthesiologist as the team leader and included an anesthesia nurse, pharmacist, and performance improvement coordinator. The FMEA model was implemented in the process of general anesthesia medications. First, the process was divided into three steps of ordering, preparation, and administration of the anesthetics. Second, identification of the failure was made (failure mode). Third, the potential effect of the failure was assessed. Fourth, criticality score was determined to detect the critical failure that was evaluated by root causes analysis, and then final recommendations or action plan were made to eliminate the risk or reduce the failure.

There were three failures in the process of ordering, eight failures in the process of preparation, and four failures in the process of administration, a total of 15 failures; there were eight critical failures that required urgent recommendations to reduce the risk, and the remaining failures were nonhigh risk that required further recommendations. All of them were reviewed and approved by the pharmacy and therapeutic committee and hospital management.

The FMEA model by a multidisciplinary team is a useful method for detecting failures for anesthesia medication errors, and a simple way to analyze the root causes of the errors; it can also find the optimal method to eliminate the risk of failure.