Recovery in FMEA

A previous essay (near miss) describes a model of preventable medical errors as following a cascade of error events whereby the cascade may be terminated by an error event -> detection -> recovery sequence (whereby detection and recovery are successful). Much has been written about detection (see detection essay) but little about recovery. Perhaps one might assume that recovery is always successful – it isn’t.

Consider the following real example of a failed recovery. The incorrect leg of a patient was scheduled to be amputated. This error event was detected but not all copies of the schedule were corrected and the incorrect leg was amputated (1).

Whereas this might seem to be an exceedingly rare event, another example illustrates the need to pay attention to recovery. Every year there are thousands of manufacturer recalls that are sent to hospitals. To get a sense of this, visit the FDA web site for recalls. One may consider  the event -> detection -> recovery sequence as having occurred across multiple sites. The original error event may have occurred at a hospital or not but has likely been reproduced in some way by the manufacturer and hence has been detected by the manufacturer. A recall notice is sent to all customers with ‘recovery’ instructions such as: throw away the following lot, or call service before using this instrument. Now I know, as a supplier of FMEA software to hospitals that the likely contact that I have with a hospital is with a purchasing agent. Hence, a successful recovery of a manufacturer recall, while simple in theory can be difficult in practice (2) and has led to patient deaths. A standards organization has completed a project to provide a guideline for recalls.

Recommendations

When one prepares a flowchart of the process, recovery should be added as a process step if there is a detection step. One may then ask whether the recovery step is adequate or needs to be improved.

References

  1. Scott D. Preventing medical mistakes. RN 2000;63:60-64
  2. Featherly K. Product recalls Patient safety’s neglected sibling Healthcare Informatics 2004;21:12
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