HEALTHCARE FAILURE MODE AND EFFECT ANALYSIS: PROSES PELAYANAN OPERASI DI RUMAH SAKIT

Abstract

Background: Most of medical errors are preventable. High
number of adverse event and near miss cases in hospitals
indicate opportunity for improvement. Therefore, efforts to
identify potential risks, recognize event as early as possible,
and set a barrier mechanism through implementation of Health
Care Failure Mode and Effect Analysis (HFMEA) are required.
This research was aimed to identify the risk of patient safety
incident (failure mode), in surgery care processes, the cause
of failure mode in every stage and the prevention strategy
using HFMEA in hospital setting.
Methods: This study employed an observation study to apply
HFMEA in surgical care processes. Data were collected through
direct observation of surgical preparation and procedures in
the ward and operating theatre, 18 interviews as well as
document analysis and focus group discussions.
Result: We found 25 activities that were not performed or
partially performed leading to 26 potential failure modes and
four critical patient safety incidents. The main cause of the
potential risk is non-effective communication. This is caused
by neglected or violation due to frequent care transitions
between departments and shifts, lack of supervision, lack of
nurse competence, and absence of full-time surgeonts. These
findings show lack of patient safety culture as the underlying
cause.
Conclusion: Poor communication and care transition is the
main causes of potential safety incident in surgery care
process. This can be prevented by process redesign and
health care teamwork improvement.
Keywords: communication, health failure mode and effect
analysis, surgery care