PCA oversedation: application of Healthcare Failure Mode Effect (HFMEA) Analysis.

Hospital systems utilize many varied problem-solving processes to address system improvements and ensure patient safety. The Healthcare Failure Mode Effect Analysis (HFMEA) model is one of these tools and uses a multidisciplinary team to look at processes, diagramming the steps involved to identify potential failure points. The application of the HFMEA model allowed one large health care system to address a complex process by prioritizing proactive change improvements in order to prevent postoperative patient-controlled anesthesia oversedation events. The changes implemented identified 16 failure points with a hazard score of 16 or greater. One year later, the established system HFMEA goal was met: oversedation events were reduced by 50%.