Health Care Failure Mode and Effect Analysis: A Useful Proactive Risk Analysis of Nutrition and Food Distribution in Mashhad Qaem Hospital’s Women’s Surgery Ward in 2013

摘要

INTRBackground and Objectives: Good medical nutrition therapy (MNT) is crucial to inpatients' health and treatment, and is part of routine hospital cares. Surgery ward is a highly danger-prone section in any hospital. The present study was conducted for a proactive risk analysis of nutrition and food distribution in Mashhad Qaem Hospital’ Women’s Surgery Ward in 2013 through health care failure mode and effect analysis (HFMEA). Materials and Methods: A qualitative-quantitative research identified and analyzed the failure modes and effects through HFMEA. To rank error modes, we drew upon nursing errors in the clinical management model to rank the effective causes of failure, we approved the model by the UK National Health System and to rank the performance improvement approaches, we used the theory of inventive problem solving, TRIZ (theory of inventive problem solving). Results: A total of 42 failure modes were identified for 15 sub-processes listed in 7 processes of nutrition and food distribution. In sum, 11.9% of the failures modes were classified as high risk (hazard scores >=8). Of 15 effective failure modes, the highest number of cause failure modes was associated with team factors, and the lowest number was associated with facilities. Conclusions: Using proactive HFMEA is highly effective in detecting potential failures in medication, effective factors in failure modes, and performance improvement approaches in hospital food distribution. 'Monitoring proper patient-wards relationship,' 'committee establishment on diet, nutrition and medications,' 'performance assessment checklist making' and 'supervising by nutrition authority over food distribution in wards' were identified as effective performance approaches in the Women’s Surgery Ward in Qaem Hospital.