Transcript Document

FMEA:
20/20 Foresight
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”
 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
 HFMEA (Healthcare FMEA) model
used
 Team first looked for previous
failures of new pump, found
general satisfaction
 Team then mapped medicationuse process with old and new
pumps
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 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
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FMEA Team Recommendations
 Mandatory user training before use, handson 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.
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
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.
Questions?
Group Dynamics
Wow, that was easy!
Fin
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