Example 6: FMEA + CPOE = Fewer Medication Errors

Issues Encountered

Pediatric chemotherapy is very complex, involves many risks, and leaves little margin for error. A Pediatric Oncology Department conducted a Failure Mode and Effect Analysis (FMEA) of their process for pediatric chemotherapy. Of the different chemotherapy steps (prescription, ordering, transcription, dispensing, and administration), the FMEA found that the modes of failure that were potentially the most severe and likely to occur took place during the ordering and administration (e.g., ordering/administering the wrong medication for/to the wrong patient).

Finding a Solution

In response to a sentinel event, and as part of a safety and quality improvement program, the Pediatric Oncology Department replaced their paper-based order entry system for pediatric chemotherapy with CPOE. They used the results of their FMEA to guide their CPOE implementation. For example, to address the risks associated with the misidentification of patients or patient variables (e.g., height, or weight) a multidisciplinary team from the hospital recommended that the CPOE incorporate the following functionalities:

  1. Limit choices (i.e., menus instead of free-text)
  2. Enforce entry of required data (i.e., user cannot navigate away until required fields are filled)
  3. Alert users to abnormal values

After the FMEA-guided implementation of the CPOE system, the Pediatric Oncology Department observed a significant reduction in the number of orders with improper dosing, incorrect dosing calculations, and missing doses.

Lesson Learned: 
  • Complex, multi-step processes are frequent sources of error.
  • Systematic methods (such as FMEA) can be used to identify potential risks in clinical process.
  • Prospective risk assessments can provide insights into which features and functionalities should be incorporated into the EHR.

Kim GR, Chen AR, Arceci RJ, et al.  Arch Pediatr Adolesc Med. 2006 May; 160(5): 495-8.

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