Health Care Failure Mode and Effect Analysis in the Operating Room Setting

Objectives: Operating rooms (ORs) and surgical settings are potential sources of sentinel adverse events. To better understand the characteristics of errors in OR processes, we performed prospective risk analysis. Methods: The study was mixed qualitative and quantitative research. We used the Healthcare Failure Mode and Effect Analysis (HFMEA) method to analyze the selected perioperative, operative, and postoperative processes in the OR via a 2-round Delphi technique. We identified the most prominent failure modes according to a Hazard Decision Matrix, analyzed and categorized proposed possible causes, and provided solutions to mitigate hazard scores. Results: Ten important processes and 7 subprocesses within the OR were selected and mapped, and 187 failure modes were identified and scored on the basis of severity and probability. A total of 36 potential failure modes were highlighted as high-risk failures and moved to decision trees for further analyses. Conclusion: Developing policy for the familiarization of new personnel designing a checklist for accurate gases counting; drafting comprehensive presurgical posters; preparing all necessary equipment in difficult intubation; developing instruction for monthly checking of the OR equipment; and developing the evaluation criteria of staff performance are examples of solutions that are proposed to improve the quality of OR processes.

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