A Failure modes and effects analysis (FMEA) is basically a methodology for predicting potential pitfalls in a project and preemptively finding solutions. This is in contrast to a root cause analysis (RCA) in which case you figure out what went wrong after the fact. Kind of like asking “what could make a plane crash and how to prevent it?” (=FMEA) versus “what made the plane crash and how do we prevent it from happening again?” (=RCA).
My current position is the first in which I’ve been involved in an FMEA, and I’ve personally found them to be powerful tools. We did an FMEA prior to implementation of our BCMA system and came up with what I thought was a pretty good list of things to look out for. Of course what the administration chooses to do with that information is a different story, but at least it’s available if needed.
I’m now involved in an FMEA for our CPOE project. It’s interesting that the issues associated with CPOE are much different than those associated with BCMA and much scarier. The scale of the CPOE project is several orders of magnitude bigger than the BCMA project. One of the biggest issues brought up during discussions on CPOE has centered on what to do when the physician selects the wrong patient or the wrong medication; notice I used “when” and not “if” because it’s going to happen. In the paper world an incorrect order is often found because the patient’s information on the physician order sheet doesn’t match the name on the chart. In the electronic world there’s no such safety. I also believe it’s significantly more difficult for the physician to grab the wrong chart than it is to select the wrong patient. I could be wrong, but I don’t think so.
How do you prevent a physician from choosing the wrong patient? Good question. Feel free to chime in at any point with a solution. One thing that crossed our minds was the use of some type of proximity system where the physician could only enter orders on a patient after scanning their wrist band or by using some type of RFID tag that automatically brings up the patient medical record when entering the room. I think it’s a valid idea, but implementation would be a bear. Throw in the fact that physicians don’t believe they can make a mistake and the battle is on.
Now assume the physician gets the patient right, but chooses the wrong drug. After all, when you search for captopril you’ll get more than one option if your hospital formulary contains more than one dosage form, tablet strength, etc. For example, depending on your system setup searching for “pro” could result in “Protonix” or “propranolol”. Both come in 40mg strengths, but they aren’t even close in what they’re used for; I’ve actually seen this error. Unless the medication ordered by the physician is wildly out of line you might never know what the intent was. The likelihood of something like this causing harm is low, but it could cause delays in therapy or possibly expose the patient to unnecessary medications. So how do you prevent this from happening? I personally think floor based pharmacists doing real-time medication evaluation and disease state management is the best approach here. Being involved with the patient’s care plan is the only real safeguard against something like this.
These are complex issues and I don’t have great solutions. If you have any ideas or have seen something in practice that might work I’d love to hear from you.