Hospitals Tackle New JCAHO Requirement with Failure Mode and Effects Analysis

By July 1, 2002, hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) must complete what JCAHO calls a "proactive risk assessment" of a high-risk process. As required by JCAHO's patient safety standard, this analysis must then be conducted on at least one high-risk process each year.

As hospitals begin to comply with the accreditation standard, they are turning to a technique called failure mode and effects analysis (FMEA) to anticipate what can go wrong with a process and to apply measures to prevent the errors. Although JCAHO's standard does not require that a hospital use FMEA, much of the terminology of FMEA is built into the intent of the JCAHO standard for proactive risk assessment.

FMEA "isn't the only way to do a proactive risk assessment," says Richard J. Croteau, M.D., JCAHO's executive director for strategic initiatives. "But it's the most extensively used in high-risk fields."

As of early 2002, most hospitals were just starting to apply FMEA to high-risk processes, such as medication use, blood transfusion, or evaluation of psychiatric patients for suicide risk. "Most hospitals are still learning to walk," says Joseph M. DeRosier, program manager at the Veterans Affairs (VA) National Center for Patient Safety, Ann Arbor, Michigan, which has developed a healthcare FMEA (HFMEA™) model for the VA's 172 medical centers. By July, VA facilities will use the model to...