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FMEA: 20/20 ForesightFMEA: 20/20 Foresight
Deirdre, RN; Kim, RNJuliana; Marija
Deirdre, RN; Kim, RNJuliana; Marija
FMEA of Alaris Smart PumpFMEA of Alaris Smart Pump“Using Failure Mode and Effects Analysis to
Plan Implementation of Smart IV Pump Technology”
“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
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
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 medication-use process with old and new pumps
HFMEA (Healthcare FMEA) model used
Team first looked for previous failures of new pump, found general satisfaction
Team then mapped medication-use 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 procedure2. Training or education3. Environment4. People5. Technology software or hardware change
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 procedure2. Training or education3. Environment4. People5. Technology software or hardware change
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FMEA Team Recommendations
FMEA Team Recommendations
Mandatory user training before use, hands-on 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)
Mandatory user training before use, hands-on 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 ???? Budget ??
No budget specifically mentioned. The
initial 22 member FMEA team included
members from central supply and
engineering that likely offered cost
analysis.
No budget specifically mentioned. The
initial 22 member FMEA team included
members from central supply and
engineering that likely offered cost
analysis.
Evaluation StrategiesEvaluation 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
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
ResultsResults 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.
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?Questions?
Group DynamicsGroup Dynamics
Wow, that was easy!
Fin
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