M09.06.008 Medical error analysis

Medical error analysis is critical for improving patient safety and healthcare quality. Two primary methods are utilized for this purpose: Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA). Each method has distinct applications and methodologies.

Design Methods

1. Root Cause Analysis (RCA)

• Definition: A retrospective approach applied after a failure event to identify and prevent recurrence.
• Purpose: To uncover the underlying issues contributing to an error.
• Methodology:
  • Data Collection: Gather records and conduct participant interviews.
  • Identification of Problems: Analyze various factors such as:
    • Process
    • People
    • Environment
    • Equipment
    • Materials
    • Management

Table 1: Root Cause Analysis Process

2. Failure Mode and Effects Analysis (FMEA)

• Definition: A forward-looking approach applied before process implementation to prevent failure occurrence.
• Purpose: To proactively identify potential failure modes in a process and mitigate risks.
• Methodology:
  • Inductive Reasoning: Consider all possible ways a process could fail.
  • Prioritization: Evaluate and rank failure modes based on:
    • Probability of occurrence
    • Impact on patients

Table 2: Failure Mode and Effects Analysis Steps

Points to Remember

• RCA is retrospective: It focuses on understanding past errors.
• FMEA is proactive: It aims to prevent errors before they occur.
• Both methods enhance patient safety and improve healthcare processes.

Bibliography

1. Institute for Healthcare Improvement. (n.d.). Root Cause Analysis. Retrieved from IHI
2. Institute for Healthcare Improvement. (n.d.). Failure Mode and Effects Analysis. Retrieved from IHI
3. AHRQ. (2020). Root Cause Analysis and Action (RCA2). Retrieved from AHRQ
4. AHRQ. (n.d.). Failure Mode and Effects Analysis (FMEA). Retrieved from AHRQ