Congress Abstracts 2006

80

USING FAILURE MODE EFFECT ANALYSIS (FMEA) TO IMPROVE MEDICATION SAFETY. Ellen Zupa, RN, MS, OCN^®, CNAA, Joanne Abbotoy, RN, BSN, and Dan Koester, RPh, Roswell Park Cancer Institute, Buffalo, NY.

Since the landmark Institute of Medicine 1999 report "To Err is Human: Building a Safer Health System" strategies to identify and adopt safe medication practices have been sought. Information technology is increasingly being implemented with the goal of improving the safety of medication processes.

In preparing for implementation of an electronic health record (EHR) including computerized prescriber order entry (CPOE) the Failure Mode Effects Analysis (FMEA) was used to determine the risks associated with current state processes and to design an electronic medication management process that reduced risk.

A multidisciplinary group used the FMEA process to proactively evaluate and reduce potential failures and harm while designing workflow processes to be implemented with the EMR.

Significant risk reduction was quantified and significant stakeholder acceptance of the proposed process changes was achieved.

This presentation will identify the value of using FMEA methodology for assessing potential failure points and patient safety issues in the high-risk patient environment of a comprehensive cancer center. This strategy could be adapted for use in any process that has the potential to impact patient safety. It was very effective in engaging oncology nurses in the process of designing workflow changes necessitated by increasing technology and to focus on the potential benefits the technology will bring to their practice.