PACS Failure Mode and Effects

PACS Failure Mode and Effects

Carrison K.S. Tong (Pamela Youde Nethersole Eastern Hospital, HK) and Eric T.T. Wong (Hong Kong Polytechnic Institute, Hong Kong)
DOI: 10.4018/978-1-59904-672-3.ch012
OnDemand PDF Download:
$37.50

Abstract

There are some medical errors for which preventability is rarely questioned. These include medical errors such as wrong site surgery, wrong procedure, wrong patient operations (Seiden & Barach, 2006; Michaels et al., 2007; Lee et al., 2007), wrong drug/dose/duration (Pugh et al., 2005) or incompatible organ transplantation (Cook et al., 2007). Less preventable medical errors include judgment type errors such as case studies reported in journals, where one or more experts review the treatment decisions of a clinician and conclude that the clinician’s judgment was incorrect (Lukela et al., 2005). Many healthcare managers first heard about Failure Mode and Effects Analysis FMEA when Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released its Leadership Standards and Elements of Performance Guidelines in July 2002 (JCAHO, 2002). The purpose of performing an FMEA for JCAHO was to identify where and when possible system failures could occur and to prevent those problems before they happen. If a particular, failure could not be prevented, then the goal would be to prevent the issue from affecting healthcare organizations in the accreditation process. FMEA is a tool that when performed adequately, can reduce the risk of preventable medical errors. Hospitals in the United States that are accredited by JCAHO are required to perform at least one FMEA each year. The main output of FMEA is a series of mitigations, each of which is some process change implemented to reduce the risk of error. Because resources are limited, implementing all mitigations is not possible so the challenge is to find the set of mitigations that provides the highest reduction in risk for the least cost. Hence, preventability may be viewed in terms of the cost and effectiveness of mitigation. A low-cost and effective mitigation is associated with a highly preventable medical error, whereas a high-cost and or less effective mitigation is associated with a less preventable medical error. Currently AAPM TG 100 (2007) is reviewing reports from previous task groups and from several professional organizations. This group is also reviewing ISO guidelines in an effort develop a suitable general QA approach that “balances patient safety and quality versus resources commonly available and strikes a good balance between prescriptiveness and flexibility.” The TG 100 initiative identifies three industrial engineering–based tools as potential components of a QA management system in radiation therapy and FMEA is one of them.
Chapter Preview
Top

Background

There are some medical errors for which preventability is rarely questioned. These include medical errors such as wrong site surgery, wrong procedure, wrong patient operations (Seiden & Barach, 2006; Michaels et al., 2007; Lee et al., 2007), wrong drug/dose/duration (Pugh et al., 2005) or incompatible organ transplantation (Cook et al., 2007). Less preventable medical errors include judgment type errors such as case studies reported in journals, where one or more experts review the treatment decisions of a clinician and conclude that the clinician’s judgment was incorrect (Lukela et al., 2005).

Many healthcare managers first heard about Failure Mode and Effects Analysis FMEA when Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released its Leadership Standards and Elements of Performance Guidelines in July 2002 (JCAHO, 2002). The purpose of performing an FMEA for JCAHO was to identify where and when possible system failures could occur and to prevent those problems before they happen. If a particular, failure could not be prevented, then the goal would be to prevent the issue from affecting healthcare organizations in the accreditation process.

FMEA is a tool that when performed adequately, can reduce the risk of preventable medical errors. Hospitals in the United States that are accredited by JCAHO are required to perform at least one FMEA each year. The main output of FMEA is a series of mitigations, each of which is some process change implemented to reduce the risk of error. Because resources are limited, implementing all mitigations is not possible so the challenge is to find the set of mitigations that provides the highest reduction in risk for the least cost. Hence, preventability may be viewed in terms of the cost and effectiveness of mitigation. A low-cost and effective mitigation is associated with a highly preventable medical error, whereas a high-cost and or less effective mitigation is associated with a less preventable medical error.

Currently AAPM TG 100 (2007) is reviewing reports from previous task groups and from several professional organizations. This group is also reviewing ISO guidelines in an effort develop a suitable general QA approach that “balances patient safety and quality versus resources commonly available and strikes a good balance between prescriptiveness and flexibility.” The TG 100 initiative identifies three industrial engineering–based tools as potential components of a QA management system in radiation therapy and FMEA is one of them.

There are a few potential problems with these recommendations, however. The first is that the general radiation therapy community is concerned that the use of these tools to reduce the risks or hazards associated with radiation therapy will require a considerable amount of additional resources. Although this should be a concern, process mapping, flowcharting tools, and FMEA (Stamatis, 1995; Fletcher, 1997; Thomadsen et al, 2003; Latino, 2004; JACHO, 2005; Hansen, 2007; Huq, 2007) have been used for decades by the medical device and pharmaceutical industries, among others, to reduce the level or risks or hazards in products and processes with many positive results. Also if the organizations are trained in the use of these tools and if these tools are applied with the assistance of experienced facilitators, there are few if any additional resources required, and the resulting process improvements will increase the effectiveness and productivity of the organization. A second potential problem is TG 100’s recommendation that these tools be used for risk and hazard analysis versus overall process improvement. This might prevent the realization of significant improvements in processes and the resulting increase in quality and productivity.

Complete Chapter List

Search this Book:
Reset
Table of Contents
Chapter 1
Introduction  (pages 1-27)
Carrison K.S. Tong, Eric T.T. Wong
Picture archiving and communications system (PACS) is a filmless and computerized method of communicating and storing medical image data such as... Sample PDF
Introduction
$37.50
Chapter 2
Carrison K.S. Tong, Eric T.T. Wong
The protection of information for a healthcare organization, in any form, while in storage, processing, or transport, from being available to any... Sample PDF
ISO 27000 Information Security Management System
$37.50
Chapter 3
Carrison K.S. Tong, Eric T.T. Wong
PACS disasters can, and do, appear in a variety of forms including storage hard disk failure, file corruption, network breakdown, and server... Sample PDF
High Availability Technologies for PACS
$37.50
Chapter 4
Carrison K.S. Tong, Eric T.T. Wong
Fundamental to ISO 27000 (ISO/IEC 27001:2005, 2005) is the concept of an information security management system (ISMS). The information security... Sample PDF
Implementation of Information Security Management System (ISMS)
$37.50
Chapter 5
Carrison K.S. Tong, Eric T.T. Wong
Filmless hospital is transforming at an unprecedented rate. Physicians, nurses, clinicians, pharmacists, radiologists, emergency departments, local... Sample PDF
Planning for a Filmless Hospital
$37.50
Chapter 6
Carrison K.S. Tong, Eric T.T. Wong
More rapidly than any technological advance in medical history, filmless hospital is changing the clinical and business aspects of radiology... Sample PDF
Design of a Filmless Hospital
$37.50
Chapter 7
Carrison K.S. Tong, Eric T.T. Wong
A PACS has tremendous benefits (Bryan, Weatherburn, Watkins, Buxton, 1999) and values outside of radiology as well as internally. The biggest... Sample PDF
Implementation of Filmless Hospital
$37.50
Chapter 8
Carrison K.S. Tong, Eric T.T. Wong
As PACS gains widespread use, the importance of Quality Control (QC), Quality Assurance (QA), and Business Continuity Plan (BCP) in PACS is rising.... Sample PDF
Quality Control, Quality Assurance, and Business Continuity Plan in PACS
$37.50
Chapter 9
PACS Quality Dimensions  (pages 140-153)
Carrison K.S. Tong, Eric T.T. Wong
A large number of studies have attempted to identify the factors that contribute to good PACS quality, such as that shown by Reiner et al (2003).... Sample PDF
PACS Quality Dimensions
$37.50
Chapter 10
Customer Oriented PACS  (pages 154-169)
Carrison K.S. Tong, Eric T.T. Wong
During the early development phase of PACS, its implementation was mainly a matter of the radiology department. This is changing rapidly, and PACS... Sample PDF
Customer Oriented PACS
$37.50
Chapter 11
Carrison K.S. Tong, Eric T.T. Wong
Nowadays it is hard to think of any applications in modern society in which electronic systems do not play a significant role. In aerospace and... Sample PDF
Design for PACS Reliability
$37.50
Chapter 12
Carrison K.S. Tong, Eric T.T. Wong
There are some medical errors for which preventability is rarely questioned. These include medical errors such as wrong site surgery, wrong... Sample PDF
PACS Failure Mode and Effects
$37.50
Chapter 13
Carrison K.S. Tong, Eric T.T. Wong
Economically speaking, it is interesting to see that over the years, the question as to whether PACS is cost-justifiable has not been easier to... Sample PDF
PACS Network Traffic Control
$37.50
Chapter 14
Human Factors and Culture  (pages 225-243)
Carrison K.S. Tong, Eric T.T. Wong
Human factors engineering (HFE) is the science of designing systems to fit human capabilities and limitations. These include limitations in... Sample PDF
Human Factors and Culture
$37.50
Chapter 15
PACS Monitoring  (pages 244-263)
Carrison K.S. Tong, Eric T.T. Wong
The present study advocates the application of statistical process control (SPC) as a performance monitoring tool for a PACS. The objective of... Sample PDF
PACS Monitoring
$37.50
Chapter 16
Carrison K.S. Tong, Eric T.T. Wong
To illustrate the benefits of implementing QM in PACS, a successful case based on the Six Sigma approach is given below. It involves a project... Sample PDF
Quality Management Benefits
$37.50
Chapter 17
Epilogue  (pages 288-297)
Carrison K.S. Tong, Eric T.T. Wong
Today’s filmless radiology through PACS provides greater speed and superior image quality. However, when workflow is encumbered by inefficiencies... Sample PDF
Epilogue
$37.50
Appendix A
Appendix B
Appendix C
About the Authors