期刊
JOURNAL OF CYSTIC FIBROSIS
卷 9, 期 4, 页码 284-287出版社
ELSEVIER
DOI: 10.1016/j.jcf.2010.04.001
关键词
Cystic fibrosis; Quality improvement; Newborn screening; Communication; Risk; PFMEA
资金
- NCRR NIH HHS [M01 RR003186, M01 RR003186-20] Funding Source: Medline
- NIDDK NIH HHS [R01 DK034108, R01 DK034108-22] Funding Source: Medline
Background: With the rapid implementation of cystic fibrosis (CF) newborn screening (NBS), quality improvement (QI) has become essential to identify and prevent errors. Using Process Failure Modes and Effects Analysis (PFMEA), we adapted this method to determine if it could be applied to discover and rank high priority QI opportunities. Methods: Site visits to three programmes were conducted, and PFMEA exercises were accomplished in Colorado, Massachusetts and Wisconsin with 23 experienced professionals. During each of these comprehensive sessions, participants identified and ranked potential failures based on severity, occurrence and detection to calculate risk priority number (RPN) values. Results: A total of 96 failure modes were generated and ranked in a list of the 20 riskiest problems that show no significant discordances by site, although there were differences by profession of the rater, particularly nurses. Conclusions: Our results illustrate that the PFMEA method applies well to CF NBS and that steps requiring communication and information transfer are perceived to be the highest risks. The number of identified failures makes and their potential impact demonstrate considerable overall risk and a need for ongoing QI. (C) 2010 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.
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