Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the Middle East

Failure mode and effects analysis-based strategies for controlling multidrug-resistant organism infections in cancer patients

In the context of advancing medical procedures, postoperative infections in cancer patients, particularly those involving multidrug-resistant organisms, have become a significant clinical concern. This study aims to comprehensively and systematically evaluate the effectiveness of infection prevention and control for multidrug-resistant organisms (MDROs) in postoperative cancer patients using Failure Mode and Effects Analysis (FMEA). This study was conducted in a tertiary A-level cancer specialty hospital in China, employing Failure Mode and Effects Analysis (FMEA) to assess the risks of hospital infections. Intervention measures were implemented for high-risk and medium-high-risk factors. Through the hospital's infection information system, data on patients who underwent surgical treatment from 2017 to 2022 were extracted. Data from 2017 to 2019 served as the control group, and data from 2020 to 2022 as the intervention group, to compare the changes in hospital infection incidence and MDRO infection incidence before and after the intervention. Categorical data were described in terms of frequency and percentage. The chi-square test was utilized for statistical inference to assess the differences in infection rates before and after the intervention. Prior to the intervention (2017-2019), the incidence rate of hospital infections was 1.66%, which decreased to 1.22% after the intervention (2020-2022), showing a statistically significant difference (χ2 = 48.83, P < 0.001). The incidence rate of MDRO infections also decreased from 1.808‰ before the intervention to 1.136‰ after the intervention, with a statistically significant difference (χ2 = 11.417, P = 0.001). This study confirms the effectiveness of the FMEA method in preventing and controlling MDRO infections in postoperative cancer patients. It highlights the practicality and value of widespread adoption of this method, particularly in the context of the COVID-19 pandemic.

Process mapping with failure mode and effects analysis to identify determinants of implementation in healthcare settings: a guide

BACKGROUND

Generating and analyzing process maps can help identify and prioritize barriers to the implementation of evidence-based practices in healthcare settings. Guidance on how to systematically apply and report these methods in implementation research is scant. We describe a method combining a qualitative approach to developing process maps with a quantitative evaluation of maps drawn from the quality improvement literature called failure mode and effects analysis (FMEA).

METHODS

We provide an outline and guidance for how investigators can use process mapping with FMEA to identify and prioritize barriers when implementing evidence-based clinical interventions. Suggestions for methods and reporting were generated based on established procedures for process mapping with FMEA and through review of original research papers which apply both methods in healthcare settings. We provide case examples to illustrate how this approach can be operationalized in implementation research.

RESULTS

The methodology of process mapping with FMEA can be divided into four broad phases: 1) formulating a plan, 2) generating process maps to identify and organize barriers over time, 3) prioritizing barriers through FMEA, and 4) devising an implementation strategy to address priority barriers. We identified 14 steps across the four phases. Two illustrative examples are provided. Case 1 describes the implementation of referrals to chiropractic care for adults with low back pain in primary care clinics. Case 2 describes the implementation of a family navigation intervention for children with autism spectrum disorder seeking care in pediatric clinics. For provisional guidance for reporting, we propose the REporting Process mapping and Analysis for Implementation Research (REPAIR) checklist.

CONCLUSIONS

Process mapping with FMEA can elucidate barriers and facilitators to successful implementation of evidence-based clinical interventions. This paper provides initial guidance for more systematic applications of this methodology in implementation research. Future research should use a consensus-building approach, such as a multidisciplinary Delphi panel, to further delineate the reporting standards for studies that use process mapping with FMEA.

Adapting Evidence-Based Practice Guidelines for Emergency Management of Seizures in Children Beyond the Neonatal Period

BACKGROUND

The presented evidence-based clinical practice guideline (CPG) is proposed as a National CPG where we adapted the international recommendations for the emergency management of seizures in children beyond the neonatal period to suit the health care in Egypt. The quality of evidence and the strength of recommendations are indicated. This study aimed to standardize the treatment of acute epileptic seizures and to provide an easy-to-apply acute treatment protocol that will allow immediate and appropriate seizure control.

METHODS

This is part of a larger program by the Egyptian Pediatric Clinical Practice Guidelines Committee (EPG) in collaboration with the staff of pediatric departments of 15 Egyptian universities and the National Research Centre. EPG was affiliated later to the Supreme Council of the Egyptian University Hospitals aiming to define the topics of, assign authors to, and assist in the adaptation of pediatric evidence-based CPGs according to a national strategic plan (http://epg.edu.eg). The committee is guided by a formal CPG adaptation methodology: the "Adapted ADAPTE."

RESULTS

The Egyptian Childhood Seizure Group (ECSG) reviewed the results of the Appraisal of Guidelines for Research and Evaluation II assessment and decided to adapt the recommendations of three source CPGs: American Epilepsy Society, Italian League Against Epilepsy, Neurocritical Care Society, and Neurologic & Psychiatric Society of Zambia. Eight implementation tools were included. A comprehensive set of multifaceted CPG implementation strategies was provided for the clinicians, patients, nurses, and other relevant stakeholders contextualized to the national settings.

CONCLUSIONS

Our experience with this adaptation methodology provides useful insight into its national utilization in Egypt.

Risk management of radioiodine treatment in differentiated thyroid cancer

INTRODUCTION

Patient safety is paramount in providing quality healthcare and constitutes a global concern for healthcare systems. Radioiodine treatment to patients with well-differentiated thyroid cancer is not without risks. The aim of this study is to identify, evaluate and mitigate the risks associated with this procedure.

MATERIALS AND METHODS

A single-centre descriptive study was conducted in which risk management was carried out by establishing a risk map using FMEA methodology.

RESULTS

Based on the process map 6 sub-processes and 23 failure modes in the three phases of the treatment process were analysed. According to risk priority number (RPN), the sub-process with the highest risk was administrative management (RPN 82), followed by treatment per se and post-treatment imaging (both with RPN 70). An overall process RPN of 300 (156 pre-treatment, 74 treatment and 70 post-treatment) was obtained. Failures directly related to the patient pose a high risk. The implementation of verification systems, performing tasks earlier and providing quality medical information are the most relevant preventive measures to be implemented.

CONCLUSIONS

The application of the FMEA methodology in the risk management for radioiodine treatment is a valuable tool for improving the quality and safety of this process. The risk map has been able to identify failures at different stages, assess their causes and effects, prioritise the risks identified and implement preventive and corrective measures that can be monitored, ensuring the effectiveness of the actions taken.

Assessing Barriers and Facilitators for Implementing Clinical Practice Guidelines in Middle Eastern and North African Region: Delphi Study

BACKGROUND

Clinical practice guidelines (CPGs) improve clinical decision making and patient outcomes, but CPG implementation is poor. The success of CPGs is influenced by several factors related to barriers and facilitators. For this reason, it can be extremely useful to explore key barriers and facilitators of CPG implementation in the Middle East and North Africa (MENA).

METHODS

A three-round Delphi study was performed using the input of 30 experts involved in the clinical practice guidelines. In the first two rounds, participants were asked to score each statement relevant to barriers or facilitators for CPG implementation on a five-point Likert scale. These statements were identified from existing systematic reviews and expert input. In round three, participants ranked the most important barriers and facilitators identified from rounds one and two. A descriptive analysis was conducted on the barrier and facilitators statements using frequencies, percentages, and medians to summarize the variables collected.

RESULTS

We identified 10 unique barriers and 13 unique facilitators to CPG implementation within the MENA region. The two highest-ranked barriers related to communications and available research and skills. The most important facilitator was the availability of training courses for healthcare professionals.

CONCLUSIONS

Key barriers and facilitators to the implementation of clinical practice guidelines seem to exist in professional, organizational, and external contexts, which should all be taken into account in order to increase implementation success within MENA region. The results of this study are useful in the design of future implementation strategies aimed at overcoming the barriers and leveraging the facilitators.

Impact of failure mode and effects analysis-based emergency management on the effectiveness of craniocerebral injury treatment

BACKGROUND

Craniocerebral injuries encompass brain injuries, skull fractures, cranial soft tissue injuries, and similar injuries. Recently, the incidence of craniocerebral injuries has increased dramatically due to the increased numbers of traffic accidents and aerial work injuries, threatening the physical and mental health of patients.

AIM

To investigate the impact of failure modes and effects analysis (FMEA)-based emergency management on craniocerebral injury treatment effectiveness.

METHODS

Eighty-four patients with craniocerebral injuries, treated at our hospital from November 2019 to March 2021, were selected and assigned, using the random number table method, to study (n = 42) and control (n = 42) groups. Patients in the control group received conventional management while those in the study group received FMEA theory-based emergency management, based on the control group. Pre- and post-interventions, details regarding the emergency situation; levels of inflammatory stress indicators [Interleukin-6 (IL-6), C-reactive protein (CRP), and procalcitonin (PCT)]; incidence of complications; prognoses; and satisfaction regarding patient care were evaluated for both groups.

RESULTS

For the study group, the assessed parameters [pre-hospital emergency response time (9.13 ± 2.37 min), time to receive a consultation (2.39 ± 0.44 min), time needed to report imaging findings (1.15 ± 4.44 min), and test reporting time (32.19 ± 6.23 min)] were shorter than those for the control group (12.78 ± 4.06 min, 3.58 ± 0.71 min, 33.49 ± 5.51 min, 50.41 ± 11.45 min, respectively; P < 0.05). Pre-intervention serum levels of IL-6 (78.71 ± 27.59 pg/mL), CRP (19.80 ± 6.77 mg/L), and PCT (3.66 ± 1.82 ng/mL) in the study group patients were not significantly different from those in the control group patients (81.31 ± 32.11 pg/mL, 21.29 ± 8.02 mg/L, and 3.95 ± 2.11 ng/mL respectively; P > 0.05); post-intervention serum indicator levels were lower in both groups than pre-intervention levels. Further, serum levels of IL-6 (17.35 ± 5.33 pg/mL), CRP (2.27 ± 0.56 mg/L), and PCT (0.22 ± 0.07 ng/mL) were lower in the study group than in the control group (30.15 ± 12.38 pg/mL, 3.13 ± 0.77 mg/L, 0.38 ± 0.12 ng/mL, respectively; P < 0.05). The complication rate observed in the study group (9.52%) was lower than that in the control group (26.19%, P < 0.05). The prognoses for the study group patients were better than those for the control patients (P < 0.05). Patient care satisfaction was higher in the study group (95.24%) than in the control group (78.57%, P < 0.05).

CONCLUSION

FMEA-based craniocerebral injury management effectively shortens the time spent on emergency care, reduces inflammatory stress and complication risk levels, and helps improve patient prognoses, while achieving high patient care satisfaction levels.

Root Cause Analysis, Failures and Effects in pediatric total quality management: a scoping review

OBJECTIVES

to analyze the applicability of Root Cause Analysis and Failure Mode and Effect Analysis tools, aiming to improve care in pediatric units.

METHODS

this is a scoping review carried out according to the Joanna Briggs Institute guidelines, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes extension for Scoping Reviews. Search took place in May 2018 on 15 data sources.

RESULTS

search totaled 8,254 studies. After using the relevant inclusion and exclusion criteria, 15 articles were included in the review. Of these, nine were published between 2013 and 2018, 12 used Failure Mode and Effect Analysis and 11 carried out interventions to improve the quality of the processes addressed, showing good post-intervention results.

FINAL CONSIDERATIONS

the application of the tools indicated significant changes and improvements in the services that implemented them, proving to be satisfactory for detecting opportunities for improvement, employing specific methodologies for harm reduction in pediatrics.

Failure mode and effects analysis for proactive healthcare risk evaluation: A systematic literature review

RATIONALE, AIMS, AND OBJECTIVES

Failure mode and effects analysis (FMEA) is a valuable reliability management tool that can preemptively identify the potential failures of a system and assess their causes and effects, thereby preventing them from occurring. The use of FMEA in the healthcare setting has become increasingly popular over the last decade, being applied to a multitude of different areas. The objective of this study is to review comprehensively the literature regarding the application of FMEA for healthcare risk analysis.

METHODS

An extensive search was carried out in the scholarly databases of Scopus and PubMed, and we only chose the academic articles which used the FMEA technique to solve healthcare risk analysis problems. Furthermore, a bibliometric analysis was performed based on the number of citations, publication year, appeared journals, authors, and country of origin.

RESULTS

A total of 158 journal papers published over the period of 1998 to 2018 were extracted and reviewed. These publications were classified into four categories (ie, healthcare process, hospital management, hospital informatization, and medical equipment and production) according to the healthcare issues to be solved, and analyzed regarding the application fields and the utilized FMEA methods.

CONCLUSION

FMEA has high practicality for healthcare quality improvement and error reduction and has been prevalently employed to improve healthcare processes in hospitals. This research supports academics and practitioners in effectively adopting the FMEA tool to proactively reduce healthcare risks and increase patient safety, and provides an insight into its state-of-the-art.

Critical failures in the use of home ventilation medical equipment

Home ventilation involves the use of medical devices at patient's home by personnel who are not healthcare practitioners. This implies new potential risks not fully addressed by current standards and guidelines. A methodological approach to investigate potential failures and define improvement actions to address the dangerous potential situations in HV is required.

A multidisciplinary team performed an extended version of Failure Mode, Effect and Criticality Analysis (FMECA) to analyse the home ventilation service provided by the Local Healthcare Unit of Naples (ASL NA1) that assisted 60 homebound ventilator dependent patients. The failures were identified in three risk areas: device, electrical system & fire hazard, and indoor air quality. The corrective actions were formulated with two extra steps: identification of critical failures with a threshold applied to the risk priority number and analysis of causes by means of contributory factors (Organization, Technology, Information, and Structure) based on Reason's theory of failures.

22 of 86 potential failures were identified as critical. Specific corrective actions were addressed and proposed through contributory factors to improve the overall quality of home ventilation service.

The use of this systemic approach oriented the improvements to reduce the harms caused by vulnerabilities in high-risk care service as life support home ventilation.

Adapting evidence-based clinical practice guidelines at university teaching hospitals: A model for the Eastern Mediterranean Region

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) are significant tools for evidence-based health care quality improvement. The CPG program at King Saud University was launched as a quality improvement program to fulfil the international accreditation standards. This program was a collaboration between the Research Chair for Evidence-Based Healthcare and Knowledge Translation and the Quality Management Department. This study aims to develop a fast-track method for adaptation of evidence-based CPGs and describe results of the program.

METHODS

Twenty-two clinical departments participated in the program. Following a CPGs awareness week directed to all health care professionals (HCPs), 22 teams were trained to set priorities, search, screen, assess, select, and customize the best available CPGs. The teams were technically supported by the program's CPG advisors. To address the local health care context, a modified version of the ADAPTE was used where recommendations were either accepted or rejected but not changed. A strict peer-review process for clinical content and methodology was employed.

RESULTS

In addition to raising awareness and building capacity, 35 CPGs were approved for implementation by March 2018. These CPGs were integrated with other existing projects such as accreditation, electronic medical records, performance management, and training and education. Preliminary implementation audits suggest a positive impact on patient outcomes. Leadership commitment was a strength, but the high turnover of the team members required frequent and extensive training for HCPs.

CONCLUSION

This model for CPG adaptation represents a quick, practical, economical method with a sense of ownership by staff. Using this modified version can be replicated in other countries to assess its validity.

Designing a smart risk analysis method for gas chlorination units of water treatment plants with combination of Failure Mode Effects Analysis, Shannon Entropy, and Petri Net Modeling

Today, all modern industrial units acknowledge the necessity of efficient and effective safety, health, and environment (HSE) systems. To become practical, these systems must be localized and customized to serve the exact needs of the industry. Nevertheless, most HSE plans are developed upon a set of common presumptions. In the water industry, gas chlorination units require strong HSE plans to mitigate the possibility of chlorine explosion and leak. This study aimed to provide an efficient HSE system for gas chlorination process within water treatment plants. This goal was achieved through a case study performed on a water treatment plant in Razavi-Khorasan province, Iran. In the first stage of this study, the researchers made combined use brainstorming sessions and modified Delphi technique to identify the risk factors of gas chlorination units and classify them into six groups in terms of association with chlorination unit building, gas cylinder storage, technical details of gas cylinders, gas cylinder transport, chlorinator connections, and chlorination unit management. In the second stage, the extracted factors were analyzed by Failure Mode Effects Analysis (FMEA) and Shannon Entropy approaches using two different panels of experts, and the results were compared for validation. Finally, the analysis results were structured by Petri Net modeling. The results showed that, according to FMEA, the risk factors with risk priority number (RPN) of over 46 are of highest importance for the studied unit. Once observed, these factors necessitate shutting down the operation until a risk mitigation solution is reached. Among the analyzed factors, (i) the presence of compounds such as NH₃, O₂, gas and liquid hydrocarbons and oil in gas chlorine cylinders and (ii) non-vertical and non-mechanized handling of full and empty cylinders during loading and unloading, with RPNs of respectively 160 and 120, were found to be significantly more important than others. In the SE analysis, in addition to the above factors, poor implementation of airflow control mechanism inside the chlorination chamber (W = 0.359), storage of chlorine cylinders near electrical and mechanical installations such as elevators or power panels (W = 0.327), poor pipe placement for connecting the injector to the water inlet and the possibility of air suction (W = 0.433), and failure to provide scientific and practical training to the chlorination staff (W = 0.342) were found to be of highest importance.