Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions

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.

Keywords: Inter-hospital transfer; Intracerebral hemorrhage; Neurocritical care; Neurology; Quality improvement; Stroke.

Figure 1:

Pre-process map [Communication components of transfer]

Figure 2:

Post-process map [Redesign of inter-hospital transfer communication]

Figure 3:

Fish-bone process map