ABSTRACT
In 2011, Nationwide Children's Hospital began using peripheral nerve catheters [PNC] to provide postoperative analgesia to patients undergoing select orthopedic and abdominal surgeries. While PNCs provide a significant improvement in the quality of care that our patients receive, introducing this new technology and process within our hospital presents an inherent risk. In order to assure that our patients received the safest care, we assembled a multi-disciplinary team to complete a proactive risk assessment by utili2ing Healthcare Failure Mode and Effect Analysis [HFMEA]. HFMEA was designed by the VA National Center for Patient Safety to identify potential failure modes within systems, and to study the consequences the failure modes have on customers. The result of this process identified and evaluated 96 failure modes and therefore 19 specific interventions were developed and deployed. The HFMEA process gives us confidence that new pain management techniques and tfieir related processes can be safely and effectively implemented in order to provide the safest and highest quality care to our patients