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Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions

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Abstract

Background/objective

Inter-hospital patient transfers for neurocritical care are increasingly common due to increased regionalization for acute care, including stroke and intracerebral hemorrhage. This process of transfer is uniquely vulnerable to errors and risk given numerous handoffs involving multiple providers, from several disciplines, located at different institutions. We present failure mode and effect analysis (FMEA) as a systems engineering methodology that can be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. Specifically, we describe our local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success.

Methods

We describe the conceptual basis for and specific use-case example for each formal step of the FMEA process. We assembled a multi-disciplinary team, developed a process map of all components required for successful transfer, and identified “failure modes” or errors that hinder completion of each subprocess. A risk or hazard analysis was conducted for each failure mode, and ones of highest impact on patient safety and outcomes were identified and prioritized for implementation. Interventions were then developed and implemented into an action plan to redesign the process. Importantly, a comprehensive evaluation method was established to monitor outcomes and reimplement interventions to provide for continual improvement.

Results

This intervention was associated with significant reductions in emergency department (ED) throughput (ED length of stay from 300 to 149 min, (p < .01), and improvements in inter-disciplinary communication (increase from pre-intervention (10%) to post- (64%) of inter-hospital transfers where the neurological intensive care unit and ED attendings discussed care for the patient prior to their arrival).

Conclusions

Application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs. Utilization of FMEA as a change instrument for quality improvement is a powerful tool for programs looking to improve timely communication, resource utilization, and ultimately patient safety.

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Acknowledgements

We acknowledge Judy Petersen for her support in developing and presenting process maps as a technical consultant for this work.

Funding

Funding was provided by Agency for Healthcare Research and Quality (Grant No. P30HS023554), National Institutes of Health (Grant No. P30AG021342), National Center for Advancing Translational Sciences (Grant No. KL2 TR000140).

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Authors and Affiliations

Authors

Contributions

AKV and SC obtained funding for this project. AKV, EF, and JS designed the study and lead the project team. KS, CM, LP, AU, VP, and MD contributed to the collection of data and analysis of study data. PC leads the drafting of the initial manuscript with critical review by all authors. AKV takes ownership for all data and writing in this manuscript.

Corresponding author

Correspondence to Arjun K. Venkatesh.

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Conflict of interest

Dr. Sheth reports grants from Novartis, grants from NIH, during the conduct of the study. Dr. Chaudhry reports and Dr. Chaudhry serves as a reviewer for the CVS Caremark State of Connecticut Clinical Program. Dr. Venkatesh reports grants from Agency for Healthcare Research and Quality, grants from NIH/NIA, grants from NIH—National Center for Advancing Translational Science, during the conduct of the study. Dr. Matouk has nothing to disclose. Dr. Chilakamarri, Dr. Finn, Dr. Sather, Dr. Parwani, Dr. Ulrich, Dr. Davis, Dr. Pham, and Dr. Chilakamarri have nothing to disclose.

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This manuscript adheres to ethical guidelines and was approved by the Yale Institutional Review Board.

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Chilakamarri, P., Finn, E.B., Sather, J. et al. Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions. Neurocrit Care 35, 232–240 (2021). https://doi.org/10.1007/s12028-020-01160-6

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  • DOI: https://doi.org/10.1007/s12028-020-01160-6

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