Failure Modes and Effects Analysis of an Electronic Quality-Checklist Process Map in Radiation Medicine: Has it Made a Difference?

2011 ◽  
Vol 81 (2) ◽  
pp. S562
Author(s):  
A. Kapur ◽  
L. Potters ◽  
R. Sharma ◽  
L. Lee ◽  
Y. Cao ◽  
...  
Keyword(s):  
Failure Modes ◽  
Process Map ◽  
Radiation Medicine ◽  
Quality Checklist

scholarly journals MRI safety management in patients with cardiac implantable electronic devices: Utilizing failure mode and effects analysis for risk optimization

2020 ◽  
Vol 32 (7) ◽  
pp. 431-437
Author(s):  
James W Ryan ◽  
Aoife S Murray ◽  
Paddy J Gilligan ◽  
James M Bisset ◽  
Chris Nolan ◽  
...  
Keyword(s):  
Risk Analysis ◽  
Failure Mode ◽  
Failure Modes ◽  
Electronic Devices ◽  
Adverse Outcomes ◽  
Process Map ◽  
Targeted Interventions ◽  
Cardiac Implantable Electronic Devices ◽  
Mr Conditional ◽  
Mri Protocol

Abstract Introduction Cardiac implantable electronic devices (CIEDs) are increasing in prevalence. Exposing patients with CIEDs to magnetic resonance imaging (MRI) can lead to adverse outcomes. This has led certain radiology departments to not accept MRI referrals related to patients with CIEDs. Patients with MR-conditional CIEDs can be safely scanned under specific conditions. Our institution has accepted such referrals since 2014. The aim of this study was to systematically identify and reduce risk in our CIED-MRI protocol using failure mode and effects analysis (FMEA). Methods A multidisciplinary FMEA team was assembled and included senior stakeholders from the CIED-MRI protocol. A process map was constructed followed by risk analysis and scoring. Targeted interventions were formulated and implemented; high-risk failure modes were prioritized. A new process map and protocol were drafted and repeat risk analysis was performed. Monitoring and re-evaluation of the CIED-MRI pathway were instigated at departmental quality assurance (QA) meetings. Results Interventions included direct CIED characterization using wireless technology pre-MRI, CIED programming and reprogramming in the MRI suite before and immediately after MRI reducing device downtime and continuous patient monitoring during MRI by a cardiac physiologist. The cumulative risk priority number (RPN) decreased from 1190 pre-FMEA to 492 post-FMEA. Discussion Despite the risk of exposing CIEDs to the MR environment, patients with MR-conditional CIEDs can be safely scanned with an appropriate multidisciplinary support. We found FMEA an indispensable tool in identifying and minimizing risk with no adverse events recorded since FMEA recommendations were implemented.

scholarly journals Offload zones to mitigate emergency medical services (EMS) offload delay in the emergency department: a process map and hazard analysis

CJEM ◽  
2015 ◽  
Vol 17 (6) ◽  
pp. 670-678 ◽  
Author(s):  
Alix J.E. Carter ◽  
James B. Gould ◽  
Peter Vanberkel ◽  
Jan L. Jensen ◽  
Jolene Cook ◽  
...  
Keyword(s):  
Emergency Department ◽  
Patient Safety ◽  
High Risk ◽  
Patient Care ◽  
Failure Modes ◽  
Hazard Analysis ◽  
Process Efficiency ◽  
Process Map ◽  
Offload Delay ◽  
The Impact

AbstractIntroductionOffload delay is a prolonged interval between ambulance arrival in the emergency department (ED) and transfer of patient care, typically occurring when EDs are crowded. The offload zone (OZ), which manages ambulance patients waiting for an ED bed, has been implemented to mitigate the impact of ED crowding on ambulance availability. Little is known about the safety or efficiency. The study objectives were to process map the OZ and conduct a hazard analysis to identify steps that could compromise patient safety or process efficiency.MethodsA Health Care Failure Mode and Effect Analysis was conducted. Failure modes (FM) were identified. For each FM, a probability to occur and severity of impact on patient safety and process efficiency was determined, and a hazard score (probability X severity) was calculated. For any hazard score considered high risk, root causes were identified, and mitigations were sought.ResultsThe OZ consists of six major processes: 1) patient transported by ambulance, 2) arrival to the ED, 3) transfer of patient care, 4) patient assessment in OZ, 5) patient care in OZ, and 6) patient transfer out of OZ; 78 FM were identified, of which 28 (35.9%) were deemed high risk and classified as impact on patient safety (n=7/28, 25.0%), process efficiency (n=10/28, 35.7%), or both (n=11/28, 39.3%). Seventeen mitigations were suggested.ConclusionThis process map and hazard analysis is a first step in understanding the safety and efficiency of the OZ. The results from this study will inform current policy and practice, and future work to reduce offload delay.

Improving patient retention by optimizing appointment scheduling in an underserved oncology population within a public safety-net health system.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 193-193
Author(s):  
Jessica Meshman ◽  
Nirav Patel ◽  
David Asher ◽  
Erudye Muniz ◽  
Mario Hidalgo ◽  
...  
Keyword(s):  
Six Sigma ◽  
Failure Modes ◽  
Safety Net ◽  
Lean Six Sigma ◽  
Appointment Scheduling ◽  
Process Map ◽  
Control Plan ◽  
Safety Net Hospital ◽  
Patient Retention

193 Background: Cancer patients in underserved populations are at high risk for patient attrition and treatment delay. We theorized that decreased appointment scheduling was contributing to a high no-show rate within an urban safety-net hospital. Clinic appointments were being scheduled in the department-specific record and verify system rather than the hospital-wide electronic health record (EHR). We sought to adopt EHR scheduling with the long-term goal of decreasing the no-show rate. Our aim was to utilize the Lean Six Sigma (LSS) methodologies to increase EHR scheduling of follow-up and rescheduling of no-show appointments to 50%. Methods: While involving the entire clinic staff, we utilized the Lean Six Sigma DMAIC model: define, measure, analyze, improve and control, to improve EHR appointment scheduling. Appointment data was collected for the 3 months prior to and during the intervention time period. We determined the root causes for delinquent scheduling, including lack of staff availability to schedule patients into two electronic systems and to call no-show patients. Interventions included implementation of an electronic order for follow-up scheduling and blocked time for personnel to contact no-show patients and verify scheduling. After the formation of a novel process map, control plan, and Failure Modes Effects Analysis (FMEA), the pilot study ran for 2 months. Results: Follow-up appointment scheduling into the EHR improved from 2% to 98% (p < 0.01). After the first intervention month, the no-show rescheduling rate improved from 0% to 43% (p < 0.01): below goal. The team revised the process map by substituting a no-show EHR order in place of the calendar intervention. This constituted the beginning of month 2 and no-show appointment rescheduling subsequently improved from 43% to 87% (p < 0.01). The patient no-show rate was 19% during the pre-intervention period, 17% for the first intervention cycle and 15% for the second intervention cycle (p = 0.3). Conclusions: Utilization of LSS allowed for successful adoption of EHR appointment scheduling within our department. While not yet significant, the no-show rate appears to be trending downward as a result of improved scheduling, and we expect the no-show rate to continue to decline as the study matures. These findings suggest that optimized appointment scheduling may decrease patient retention in an at-risk population. Future directions include evaluating cancer outcomes and decreased healthcare costs as a result of higher patient retention.

Scanning Electron Microscopy in Hybrid Microelectronics

1976 ◽  
Vol 34 ◽  
pp. 456-457
Author(s):  
S. Khadpe ◽  
R. Faryniak
Keyword(s):  
Integrated Circuits ◽  
Thick Film ◽  
Integrated Circuit ◽  
Failure Modes ◽  
Three Dimensional ◽  
Circuit Components ◽  
Hybrid Microcircuit ◽  
Electrical Connections ◽  
Scanning Electron

The Scanning Electron Microscope (SEM) is an important tool in Thick Film Hybrid Microcircuits Manufacturing because of its large depth of focus and three dimensional capability. This paper discusses some of the important areas in which the SEM is used to monitor process control and component failure modes during the various stages of manufacture of a typical hybrid microcircuit.Figure 1 shows a thick film hybrid microcircuit used in a Motorola Paging Receiver. The circuit consists of thick film resistors and conductors screened and fired on a ceramic (aluminum oxide) substrate. Two integrated circuit dice are bonded to the conductors by means of conductive epoxy and electrical connections from each integrated circuit to the substrate are made by ultrasonically bonding 1 mil aluminum wires from the die pads to appropriate conductor pads on the substrate. In addition to the integrated circuits and the resistors, the circuit includes seven chip capacitors soldered onto the substrate. Some of the important considerations involved in the selection and reliability aspects of the hybrid circuit components are: (a) the quality of the substrate; (b) the surface structure of the thick film conductors; (c) the metallization characteristics of the integrated circuit; and (d) the quality of the wire bond interconnections.

Human reliability in non-destructive inspections of nuclear power plant components: modeling and analysis

2019 ◽  
Vol 7 (2B) ◽  
Author(s):  
Vanderley Vasconcelos ◽  
Wellington Antonio Soares ◽  
Raissa Oliveira Marques ◽  
Silvério Ferreira Silva Jr ◽  
Amanda Laureano Raso
Keyword(s):  
Power Plant ◽  
Nuclear Power Plant ◽  
Human Factors ◽  
Nuclear Power ◽  
Power Plants ◽  
Failure Modes ◽  
Cooling System ◽  
Human Reliability ◽  
Non Destructive ◽  
Plant Components

Non-destructive inspection (NDI) is one of the key elements in ensuring quality of engineering systems and their safe use. This inspection is a very complex task, during which the inspectors have to rely on their sensory, perceptual, cognitive, and motor skills. It requires high vigilance once it is often carried out on large components, over a long period of time, and in hostile environments and restriction of workplace. A successful NDI requires careful planning, choice of appropriate NDI methods and inspection procedures, as well as qualified and trained inspection personnel. A failure of NDI to detect critical defects in safety-related components of nuclear power plants, for instance, may lead to catastrophic consequences for workers, public and environment. Therefore, ensuring that NDI is reliable and capable of detecting all critical defects is of utmost importance. Despite increased use of automation in NDI, human inspectors, and thus human factors, still play an important role in NDI reliability. Human reliability is the probability of humans conducting specific tasks with satisfactory performance. Many techniques are suitable for modeling and analyzing human reliability in NDI of nuclear power plant components, such as FMEA (Failure Modes and Effects Analysis) and THERP (Technique for Human Error Rate Prediction). An example by using qualitative and quantitative assessesments with these two techniques to improve typical NDI of pipe segments of a core cooling system of a nuclear power plant, through acting on human factors issues, is presented.

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