1261 / Implementing the FMEA technique to control laboratory risk in assisted reproduction

ITALY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Analysis of risk and harm
Assessment of risk and harm There is no specified text here
Topic of the reported practice
Quality improvement project
Aim and the benefit of the Patient Safety Practice
 
In the assisted reproduction (AR) laboratory, several procedures are involved in the retrieval, manipulation, evaluation and culture of gametes and embryos, associated with different risk profiles and potential failures. Purpose of this intervention was to assess the risk of failure through FMEA methodology in order to identify real or potential breakdowns in processes and consequently develop strategies to reduce risks.
Description of the Patient Safety Practice
 
Failure Modes and Effects Analysis (FMEA) is a systematic, proactive method that allows to assess where and how a process might fail and the relative impact of different failures, in order to identify the phases of the process that are most in need of change. FMEA includes review of the following: 1) Steps in the process; 2) Failure modes (What could go wrong?); 3) Failure causes (Why would the failure happen?); 4)Failure effects (What would be the consequences of each failure?). Teams use FMEA to evaluate processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. In the context of AR, this emphasis on prevention may reduce risk of harm, lose or exchange of gametes/embryos. FMEA is particularly useful in evaluating a new process prior to implementation and in assessing the impact of a proposed change to an existing process. A typical FMEA incorporates a method to evaluate the risk associated with the potential problems identified through the analysis. To calculate the Risk Priority Number (RPN), the analysis team must rate the severity of every failure mode, the event probability and the identifiability of the event (i.e. the likelihood of detecting the problem before it reaches the end user or customer). RPN is used to plan changes in practices to mitigate the risk of failures. An RPN of 4 has been calculated for critical instrument breaks while an RPN of 20 has been found for gametes and embryos mixups. A reduction in risk associated with instrument breaks has been obtained by the introducing a maintenance program, while a reduction in risk associated with sample mixups has been obtained by introducing a human witness in the most critical processes.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Unit or ward level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
No
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Scientific staff / researchers
Quality manager
Risk manager
Other or not relevant
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
http://buonepratiche.agenas.it/questionnaire.aspx?id=5195
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Yes
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Motivated staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Paola Vigano
Country: ITALY
Organisation: IRCCS S. RAFFAELE - MILANO
E-mail: vigano.paola@hsr.it
Phone: There is no specified text here
Print
Top
At la sikisen cesaretli kadina 50 cm at yarragi giriyor hayvanli porno izle
sirinevler escort sirinevler escort atakoy escort mecidiyekoy escort etiler escort atasehir escort capa escort
usak escort elazig escort
sex filme
porno
sirinevler escort beylikduzu escort atakoy escort sisli escort atakoy escort sisli escort sirinevler escort beylikduzu escort halkali escort halkali escort istanbul escort beylikduzu escort beylikduzu escort sirinevler escort sirinevler escort beylikd�z� escort �i�li escort �irinevler escort avrupa yakasi escort �apa escort beylikd�z� escort