Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation

Progress in Transplantation, Sep 2009 by Steinberger, Dina M, Douglas, Stephen V, Kirschbaum, Mark S

A multidisciplinary team from the University of Wisconsin Hospital and Clinics transplant program used failure mode and effects analysis to proactively examine opportunities for communication and handoff failures across the continuum of care from organ procurement to transplantation. The team performed a modified failure mode and effects analysis that isolated the multiple linked, serial, and complex information exchanges occurring during the transplantation of one solid organ. Failure mode and effects analysis proved effective for engaging a diverse group of persons who had an investment in the outcome in analysis and discussion of opportunities to improve the system's resilience for avoiding errors during a timepressured and complex process. (Progress in Transplantation. 2009;19:208-215)

Notice to CE enrollees:

A closed-book, multiple-choice examination after this article tests your ability to accomplish the following objectives:

1 . Discuss the complexity of system enors and the role of hidden or "latent" conditions that produce enors

2. Articulate the purpose of proactive risk assessment

3. Describe the process of performing a structured analysis using the Failure Mode and Effects Analysis (FMEA) method

4. Determine 3 ways that FMEA can be an effective and flexible tool for analyzing and improving transplant processes across the continuum of care

A conservative estimate is that at least 48 handoffs of significant information involving a minimum of 20 clinicians, staff, and family members occur in the continuum from organ procurement to transplantation care during the placement of 1 solid organ. Despite a multitude of safety checks and verification mechanisms, errors do occur and the associated costs are significant. At a minimum, delays ensue and expensive resources (personnel time, operating room services) are wasted. More serious outcomes include donor organs compromised as a result of prolonged cold ischemia time or life-threatening donor-recipient mismatches. Communication and handoff problems are not uncommon in health care. The Joint Commission reports, "Inadequate communication between care providers or between care providers and patients/families is consistently the main root cause of sentinel events." Furthermore, they report that 75% of these communication-based events lead to death.'

The prevalence of communication failures in health care results not only from the sheer volume of information exchanged but also from the many ways that communication channels can be disrupted and information mishandled. Although a lack of information may result in errors from uninformed actions, the problem in today's data-rich, technological environments becomes one of having too much information. The burden then becomes sifting through the less-critical, irrelevant, or bloated information to find- and then interpret- relevant information, generally while within a time-pressured context. The resulting "cognitive overload" adversely affects decision making and distorts situational awareness.2

One study of decision support and information systems cites examples of adverse outcomes associated with information mismanagement.3 In one case, it was shown that adverse events increase significantly during periods of physician cross-coverage. Another example cites critical laboratory values that, although promptly reported in an information system, are overlooked because of the large volume of normal and less critical values.

Leonard et al4 suggest that the training and communication styles of nurses and physicians are fundamentally different, and the differences contribute to miscommunication. It is common for nurses, for example, to provide broad, narrative descriptions when consulting physicians. Conversely, physicians, looking for diagnostic cues, want them to "get to the point"; that is, provide only factual highlights concerning what they view to be the situation at hand. By definition, communication involves multiple participants, and it is rare for 1 person or factor to lead to a communication breakdown. Typically a series of hidden, or "latent," flaws in the system interact to produce a failure.5 Unfortunately, the recipient of the failure may be a well-intentioned clinician or patient.

After experiencing 2 unrelated adverse events within a year, the Quality Resources Department at the University of Wisconsin Hospital and Clinics determined that the logistical complexities and time pressures associated with organ transplantation created a high-risk work flow and was worthy of additional analysis. Consequently, we launched a prospective risk analysis that used the Failure Mode and Effects Analysis (FMEA) method. Root cause analyses were conducted after each patient event to identify the contributing factors, to isolate primary causes, and to act to reduce future risk.6

Both root cause analysis and FMEA are useful tools in efforts to better understand complex systems and to cultivate high reliability within organizations. FMEA is a process historically used in manufacturing settings and is often employed in high-risk industries such as aerospace and the military. The FMEA framework was developed by the military in 1949 and is described as follows: