Enhancing Patient Safety: Optimizing Fall Risk Management for Oncology Patients through Failure Modes and Effects Analysis

Abstract

Objective: This study aimed to enhance patient safety by optimizing fall risk management for oncology patients utilizing Failure Modes and Effects Analysis (FMEA) within outpatient settings. Methods: The project was conducted at the SQCCCRC, focusing on outpatient clinics, daycare, radiology, radiotherapy, and rehabilitation. An observational analytical design was employed to evaluate the fall risk assessment process pre and post-interventions. A 7-step FMEA methodology was applied, involving defining the system, identifying potential failure modes, assessing their effects, assigning severity, likelihood, and detection ratings, and implementing corrective actions. Risk Priority Numbers (RPNs) were used to gauge the impact of interventions on reducing fall risk. Results: Following interventions, substantial reductions in RPNs were observed in various failure modes such as “Wrong assessment” (57% decrease), “Complex risk assessment scale” (63% decrease), and “Missed fall assessment” (80% decrease). Improvements were also noted in fall risk precaution measures, with reductions in RPNs for “Unclear fall precaution measures-responsibilities” (80% decrease) and “Missed bracelets for high risk” (57% decrease). In the Patient Education process, significant RPN reductions were seen for “No/improper education” (57% decrease) and “Unuse of educational material and resources” (55% decrease). Overall, there was a 62% reduction in RPNs across all failure modes in patient fall assessment and management. Conclusion: FMEA proves to be a valuable strategy for mitigating fall risks among oncology patients. However, success hinges on addressing identified limitations and ensuring the thorough implementation and maintenance of corrective actions.