VHA National Center for Patient Safety

An HFMEA is five-step process teams use to proactively evaluate a health care process.

In July 2013 the Birmingham VA Medical Center formed a team to complete their annual Healthcare Failure Mode Effect Analysis (HFMEA). It was comprised of staff from services believed to have the greatest potential impact on the success of the subject selected for analysis: identifying and searching for an absent or missing patient.

An HFMEA is five-step process used to proactively evaluate a health care process. Specifically designed for use by health care professionals, the process offers users analytical tools such as flow diagramming, decision trees and prioritized scoring systems.

The topic was selected due to the facility location, the number of construction projects underway, the number of near miss events, and the medical center’s commitment to safety of Veterans.

“A review of the guidance for managing these events quickly showed the lack of a standardized and coordinated approach,” said the facility’s Patient Safety Manager Shawana Barnes, R.N., M.S.N. “Due to the urgency of completing our mission, the team chose to meet for three consecutive days: four hours the first day, followed by two eight-hour days. Our goal was to complete the foundation of the project by close of business on the third day.”

The team defined an absent patient as a competent patient who leaves a treatment area without the knowledge or permission of staff, but who does not meet the criteria for a missing patient and is not considered incapacitated. A missing patient was defined as an at-risk patient who disappears from an inpatient or outpatient treatment area.

The team’s mission was to determine if there were gaps in current processes that needed to be corrected. “We initially felt that we all knew what was expected of us, as well as how other staff would respond when a Veteran was reported to be missing,” she said. “But based on our initial conversations, we quickly determined that there were different sets of responses, even within our small group.”

For instance, some services used an established internal telephone cascade to alert others within their service. Other services alerted only those in their immediate surroundings, never contacting staff members who were stationed on another floor. “We also found a difference of opinion regarding which patients should be treated as absent and which should be treated as missing,” Barnes noted.

The team discovered that construction areas were a determinant as to whether the Veteran would be identified as missing or absent, “We took a walk through our construction areas, quickly learning that there was more construction going than we had been aware of,” she said. “Additionally, we discovered that there were places that might not be explored if staff weren’t advised that those areas needed to be searched; basically, more places to hide.”

The team determined their top priority was to find a consistent way to inform staff on how best to prevent missing patient events, as well as develop related tools that would be useful and easily accessible.

Additional Information 

Read the entire story in the March/April edition of TIPS

More information on the HFMEA process is available in our On the Job Tools section

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