Using HFMEA to assess potential for patient harm from tubing misconnections.

Background: Reported cases of tubing misconnections and other tubing errors prompted Columbus Children's Hospital to study their potential for harm in its patient population. A Health Failure Mode and Effects Analysis (HFMEA) was conducted in October 2004 to determine the risks inherent in the use and labeling of various enteral, parenteral, and other tubing types in patient care and the potential for patient harm.

Methods: An assessment of the practice culture revealed considerable variability among nurses and respiratory therapists within and between units. Work on an HFMEA culminated in recommendations of risk reduction strategies. These included standardizing the process of labeling of tubing throughout the organization, developing an online pictorial catalog to list available tubing supplies with all aliases used by staff, and conducting an inventory of all supplies to identify products that need to be purchased or discontinued. Three groups are working on implementing each of the recommendations.

Results: Most of the results already realized occurred in labeling of tubing. The pediatric intensive care unit labels all tubing with infused medications 85% of the time; tubings inserted during surgery or in interventional radiology are labeled 53% and 93% of the time. Pocket-size cards with printed labels were tested in three units.

Discussion: This proactive risk assessment project has identified failure modes and possible causes and solutions; several recommendations have been implemented. No tubing misconnections have been reported.