Improving Team Members' Attention During the OR Briefing or Time Out.

Effective coordination among health care professionals is crucial to achieving optimal outcomes. In the OR, even minor errors can have catastrophic consequences. To mitigate the risk of error, health care professionals have adopted a briefing culture like that used in the aviation industry. Briefings are essential to ensure that everyone involved in a procedure knows the plan and potential risks and is prepared to perform their duties safely and effectively. The fundamental human sense involved in briefings is auditory perception; although important, hearing alone does not equate to focused attention. To enhance the efficacy of briefings, engaging the use of a second sense by adding a visual checklist may increase attentiveness and the chances of early error detection and prevention. Using a projection device may enhance all team members' engagement and participation during the briefing or time-out process and can be an effective tool for improving communication and reducing errors.

Enhancing Patient Safety Through Effective Interprofessional Communication: A Focus on Medication Error Prevention.

BACKGROUND: Medication errors significantly impact patient safety and healthcare costs. This study investigates the influence of interprofessional communication on medication error rates, with a focus on identifying actionable strategies to improve communication efficacy among healthcare professionals. METHODS: Utilizing a quantitative approach, this research distributed a detailed online questionnaire to a broad cohort of healthcare workers in various settings within Saudi Arabia. The survey encompassed sections on demographics, the frequency and quality of interprofessional communication, perceived barriers and facilitators to effective communication, and personal experiences with medication errors. Statistical analysis was performed using SPSS to derive descriptive and inferential statistics, alongside thematic analysis for qualitative responses. RESULTS: The survey attracted 1165 respondents, predominantly aged 20-30 (68.58%) and female (65.49%). Pharmacists constituted the largest professional group (40.34%). We identified a notable positive correlation (r = 0.16) between high-quality interprofessional communication and employment in hospital environments or having 5-20 years of experience. In contrast, negative correlations were observed with employment in non-traditional healthcare settings (r = -0.19) and professionals with less than five years of experience (r = -0.13), indicating communication challenges. The analysis also highlighted a concerning frequency of prescription and dispensing errors, with 52.70% of participants reporting prescription errors as the most common issue encountered. CONCLUSION: Effective interprofessional communication is pivotal in mitigating medication errors within healthcare settings. The study illuminates specific areas for improvement, including the need for targeted communication training, particularly for less experienced professionals and those in non-traditional settings. Enhancing communication channels and fostering an environment conducive to open, interdisciplinary dialogue are essential steps towards advancing patient safety and reducing medication errors.

AAPM WGPE report 394: Simulated error training for the physics plan and chart review.

BACKGROUND: Simulated error training is a method to practice error detection in situations where the occurrence of error is low. Such is the case for the physics plan and chart review where a physicist may check several plans before encountering a significant problem. By simulating potentially hazardous errors, physicists can become familiar with how they manifest and learn from mistakes made during a simulated plan review. PURPOSE: The purpose of this project was to develop a series of training datasets that allows medical physicists and trainees to practice plan and chart reviews in a way that is familiar and accessible, and to provide exposure to the various failure modes (FMs) encountered in clinical scenarios. METHODS: A series of training datasets have been developed that include a variety of embedded errors based on the risk-assessment performed by American Association of Physicists in Medicine (AAPM) Task Group 275 for the physics plan and chart review. The training datasets comprise documentation, screen shots, and digital content derived from common treatment planning and radiation oncology information systems and are available via the Cloud-based platform ProKnow. RESULTS: Overall, 20 datasets have been created incorporating various software systems (Mosaiq, ARIA, Eclipse, RayStation, Pinnacle) and delivery techniques. A total of 110 errors representing 50 different FMs were embedded with the 20 datasets. The project was piloted at the 2021 AAPM Annual Meeting in a workshop where participants had the opportunity to review cases and answer survey questions related to errors they detected and their perception of the project's efficacy. In general, attendees detected higher-priority FMs at a higher rate, though no correlation was found between detection rate and the detectability of the FMs. Familiarity with a given system appeared to play a role in detecting errors, specifically when related to missing information at different locations within a given software system. Overall, 96% of respondents either agreed or strongly agreed that the ProKnow portal and training datasets were effective as a training tool, and 75% of respondents agreed or strongly agreed that they planned to use the tool at their local institution. CONCLUSIONS: The datasets and digital platform provide a standardized and accessible tool for training, performance assessment, and continuing education regarding the physics plan and chart review. Work is ongoing to expand the project to include more modalities, radiation oncology treatment planning and information systems, and FMs based on emerging techniques such as auto-contouring and auto-planning.

The interrelatedness of error prevention and error management.

We study errors in organizations to understand and ideally prevent them from reoccurring. In this study we examine mistakes made as an oil company adopted new technology to access untapped reserves. We find that a pre-existing error management culture (EMC) dominated in the organization while error prevention measures were deficient. This is surprising given the complexity of the business and the importance of safety. We show that a balance between error prevention and error management is difficult to achieve owing to the contradictory nature of these approaches. While the extant organizational error literature identifies the complementary aspect of error prevention and error management it does not consider their interrelatedness-how one affects the other. We find that the dominating error management culture at Suncor Energy contributed to error prevention processes that were misapplied, informal or absent. This highlights the need for deliberate examination of error approaches especially as the business context shifts.

Prevalence and factors predisposing to potential drug-drug interactions in a Polish community-dwelling geriatric population: An observational, cross-sectional study.

BACKGROUND: Due to advanced age, multimorbidity and polypharmacotherapy, older patients are predisposed to drug interactions and the adverse effects of inappropriate drug combinations. OBJECTIVES: To provide up-to-date data on predisposing factors and the prevalence of possible drug interactions in the Polish geriatric population and to promote automated analysis programs as part of safe pharmacotherapy. MATERIAL AND METHODS: We used the Lexicomp® Drug Interactions database to assess pharmacological interactions between active substances included in all types of preparations (prescription drugs, over-the-counter drugs, vitamins, nutritional preparations, and dietary supplements) used at least once in the 2 weeks preceding the study, among 2633 home-dwelling people aged >65 years. The variables measured included age, sex, place of residence, level of education, and multimorbidity. Post-stratification was used to weigh the sample structure against the Polish population in 2017. RESULTS: Drug interactions were identified in 81.2% of all individuals. The mean number (with 95% confidence interval (95% CI)) of all drug interactions was 4.24 (4.02-4.46), and the median value (with 1st and 3rd quartiles (Q1-Q3)) was 3 (1-6). At least 1 category C interaction was observed in 75.8% of all study participants, 24.3% had 1 or more category D interaction, and 4.3% had 1 or more category X interaction. The most important predisposing factor to drug interactions was multimorbidity. CONCLUSIONS: This study identified a high prevalence of potential drug interactions in the Polish geriatric population. Automated analysis systems deliver useful information on pharmacological interactions and should be promoted in the Polish healthcare community as tools to support pharmacotherapy.

Electroencephalography can provide advance warning of technical errors during laparoscopic surgery.

BACKGROUND: Intraoperative adverse events lead to patient injury and death, and are increasing. Early warning systems (EWSs) have been used to detect patient deterioration and save lives. However, few studies have used EWSs to monitor surgical performance and caution about imminent technical errors. Previous (non-surgical) research has investigated neural activity to predict future motor errors using electroencephalography (EEG). The present proof-of-concept cohort study investigates whether EEG could predict technical errors in surgery. METHODS: In a large academic hospital, three surgical fellows performed 12 elective laparoscopic general surgeries. Audiovisual data of the operating room and the surgeon's neural activity were recorded. Technical errors and epochs of good surgical performance were coded into events. Neural activity was observed 40 s prior and 10 s after errors and good events to determine how far in advance errors were detected. A hierarchical regression model was used to account for possible clustering within surgeons. This prospective, proof-of-concept, cohort study was conducted from July to November 2021, with a pilot period from February to March 2020 used to optimize the technique of data capture and included participants who were blinded from study hypotheses. RESULTS: Forty-five technical errors, mainly due to too little force or distance (n = 39), and 27 good surgical events were coded during grasping and dissection. Neural activity representing error monitoring (p = .008) and motor uncertainty (p = .034) was detected 17 s prior to errors, but not prior to good surgical performance. CONCLUSIONS: These results show that distinct neural signatures are predictive of technical error in laparoscopic surgery. If replicated with low false-alarm rates, an EEG-based EWS of technical errors could be used to improve individualized surgical training by flagging imminent unsafe actions-before errors occur and cause patient harm.

Assessment of the Use of Patient Vital Sign Data for Preventing Misidentification and Medical Errors.

Patient misidentification is a preventable issue that contributes to medical errors. When patients are confused with each other, they can be given the wrong medication or unneeded surgeries. Unconscious, juvenile, and mentally impaired patients represent particular areas of concern, due to their potential inability to confirm their identity or the possibility that they may inadvertently respond to an incorrect patient name (in the case of juveniles and the mentally impaired). This paper evaluates the use of patient vital sign data, within an enabling artificial intelligence (AI) framework, for the purposes of patient identification. The AI technique utilized is both explainable (meaning that its decision-making process is human understandable) and defensible (meaning that its decision-making pathways cannot be altered, just optimized). It is used to identify patients based on standard vital sign data. Analysis is presented on the efficacy of doing this, for the purposes of catching misidentification and preventing error.

Multi-Cellular Immunological Interactions Associated With COVID-19 Infections.

To rapidly prognosticate and generate hypotheses on pathogenesis, leukocyte multi-cellularity was evaluated in SARS-CoV-2 infected patients treated in India or the United States (152 individuals, 384 temporal observations). Within hospital (<90-day) death or discharge were retrospectively predicted based on the admission complete blood cell counts (CBC). Two methods were applied: (i) a "reductionist" one, which analyzes each cell type separately, and (ii) a "non-reductionist" method, which estimates multi-cellularity. The second approach uses a proprietary software package that detects distinct data patterns generated by complex and hypothetical indicators and reveals each data pattern's immunological content and associated outcome(s). In the Indian population, the analysis of isolated cell types did not separate survivors from non-survivors. In contrast, multi-cellular data patterns differentiated six groups of patients, including, in two groups, 95.5% of all survivors. Some data structures revealed one data point-wide line of observations, which informed at a personalized level and identified 97.8% of all non-survivors. Discovery was also fostered: some non-survivors were characterized by low monocyte/lymphocyte ratio levels. When both populations were analyzed with the non-reductionist method, they displayed results that suggested survivors and non-survivors differed immunologically as early as hospitalization day 1.

Using failure mode and Effects Analysis to increase patient safety in cancer chemotherapy.

BACKGROUND: Medication errors may occur during chemotherapy and can have fatal consequences. Healthcare Failure Mode and Effects Analysis (FMEA) is a method used to detect potential risks and prevent them. OBJECTIVE: Aim of this study was to evaluate the medication process of intravenous tumor therapy in order to guarantee a high standard of patient safety. METHODS: The main part of the study was performed at the University Hospital of Bonn, Germany. After assembling a multidisciplinary team, the individual steps of prescription, compounding, transport, and administration of chemotherapy were mapped in a flow diagram. The possible failures were identified and analyzed by calculating the risk priority numbers (RPNs). Finally, corrective actions were developed and after hypothetical implementation re-analyzed to measure their effects on the process. Subsequently, a shortened FMEA based on the catalogue failure modes developed in Bonn was carried out at the University Hospital of Cologne in order to evaluate its transferability to another hospital. RESULTS: A total of 52 potential failure modes was identified in Bonn. Relating to the RPNs the most critically steps in the process were associated with the prescription, namely, incorrect information about individual parameters of the patient; non-standardized chemotherapy protocols; and problems related to supportive therapy. A significant risk reduction for most of the failure modes was assessed by implementing suitable corrective actions. The shortened FMEA in Cologne led to a different ranking of failure modes. CONCLUSION: The implementation of this analysis has not only identified various safety gaps, but also shows how patient safety during chemotherapy can be enhanced. Moreover, it has sensitized the practitioners to failure modes potentially occurring in their work routine.

Top-Down Processing of Drug Names Can Induce Errors in Discriminating Similar Pseudo-Drug Names by Nurses.

BACKGROUND: One factor that could cause medical errors is confusing medicines with similar names. A previous study showed that nurses who have knowledge about drugs faced difficulty in discriminating a drug name from similar pseudo-drug names. To avoid such errors, finger-pointing and calling (FPC) has been recommended in Japan. OBJECTIVES: The present study had two aims. The first was to determine whether such difficulty was due to top-down processing, rather than bottom-up processing, being applied even for pseudo-names. The other was to investigate whether FPC affected error prevention for similar drug names. METHOD: In two experiments, nurses and non-health care professionals performed a choice reaction time task for drug names and common words, with or without FPC. Error rate and reaction time were analyzed. RESULTS: When drug names were used, nurses showed difficulty discriminating target names from distractors. Furthermore, the error prevention effect of FPC was marginally significant for drug names. However, nurses showed no significant differences when similar drug names were used. There was no significant difference regarding the error rate for words. CONCLUSIONS: Nurses' knowledge of drug names activates top-down processing. As a result, the processing of drug names was not as accurate and quick as that for words for nurses, which caused difficulty in discriminating similar names. FPC may be applicable to reduce confusion errors, possibly by leading individuals to process drug names using bottom-up processing. APPLICATION: The present study advances current knowledge about error tendencies with similar drug names and the effects of FPC on error prevention.

The role of surface-guided radiation therapy for improving patient safety.

Emerging data indicates SGRT could improve safety and quality by preventing errors in its capacity as an independent system in the treatment room. The aim of this work is to investigate the utility of SGRT in the context of safety and quality. Three incident learning systems (ILS) were reviewed to categorize and quantify errors that could have been prevented with SGRT: SAFRON (International Atomic Energy Agency), UW-ILS (University of Washington) and AvIC (Skåne University Hospital). A total of 849/9737 events occurred during the pre-treatment review/verification and treatment stages. Of these, 179 (21%) events were predicted to have been preventable with SGRT. The most common preventable events were wrong isocentre (43%) and incorrect accessories (34%), which appeared at comparable rates among SAFRON and UW-ILS. The proportion of events due to wrong accessories was much smaller in the AvIC ILS, which may be attributable to the mandatory use of SGRT in Sweden. Several case scenarios are presented to demonstrate that SGRT operates as a valuable complement to other quality-improvement tools routinely used in radiotherapy. Cases are noted in which SGRT itself caused incidents. These were mostly related to workflow issues and were of low severity. Severity data indicated that events with the potential to be mitigated by SGRT were of higher severity for all categories except wrong accessories. Improved vendor integration of SGRT systems within the overall workflow could further enhance its clinical utility. SGRT is a valuable tool with the potential to increase patient safety and treatment quality in radiotherapy.

Mors Gaudet Succurrere Vitae. The Role of Clinical Autopsy in Preventing Litigation Related to the Management of Liver and Digestive Disorders.

Over the last 50 years, the number of clinical autopsies has decreased, but their role in assessing cause of death and clinical performance is still acknowledged. Few publications have studied their role in malpractice claim prevention. The paper aims to highlight the role of clinical autopsy in preventing errors and improve healthcare quality. A retrospective study was conducted on 28 clinical autopsies performed between 2015 and 2021 on patients dead unexpectedly after procedures for the diagnosis and treatment of digestive and hepatic diseases. After an accurate analysis of medical records and consultation with healthcare professionals, all cases were subjected to autopsy and histopathology. The data obtained were analyzed and shared with the risk-management team to identify pitfalls and preventive strategies. Post-mortem evaluations confirmed the clinical diagnosis only in six cases (21.4%). Discordances were observed in 10 cases (35.7%). In the remaining 12 cases (42.9%) the clinical diagnosis was labeled as "unknown" and post-mortem examinations made it possible to document the cause of death. Post-mortem examinations can concretely enrich hospital prevention systems and improve patient safety. The methodological approach outlined certainly demonstrates that, even in the risk-management field, "mors gaudet succurrere vitae" ("death delights in helping life").

Evaluation of an optimized context-aware clinical decision support system for drug-drug interaction screening.

OBJECTIVE: Evaluation of the effect of six optimization strategies in a clinical decision support system (CDSS) for drug-drug interaction (DDI) screening on alert burden and alert acceptance and description of clinical pharmacist intervention acceptance. METHODS: Optimizations in the new CDSS were the customization of the knowledge base (with addition of 67 extra DDIs and changes in severity classification), a new alert design, required override reasons for the most serious alerts, the creation of DDI-specific screening intervals, patient-specific alerting, and a real-time follow-up system of all alerts by clinical pharmacists with interventions by telephone was introduced. The alert acceptance was evaluated both at the prescription level (i.e. prescription acceptance, was the DDI prescribed?) and at the administration level (i.e. administration acceptance, did the DDI actually take place?). Finally, the new follow-up system was evaluated by assessing the acceptance of clinical pharmacist's interventions. RESULTS: In the pre-intervention period, 1087 alerts (92.0 % level 1 alerts) were triggered, accounting for 19 different DDIs. In the post-intervention period, 2630 alerts (38.4 % level 1 alerts) were triggered, representing 86 different DDIs. The relative risk forprescription acceptance in the post-intervention period compared to the pre-intervention period was 4.02 (95 % confidence interval (CI) 3.17-5.10; 25.5 % versus 6.3 %). The relative risk for administration acceptance was 1.16 (95 % CI 1.08-1.25; 54.4 % versus 46.7 %). Finally, 86.9 % of the clinical pharmacist interventions were accepted. CONCLUSION: Six concurrently implemented CDSS optimization strategies resulted in a high alert acceptance and clinical pharmacist intervention acceptance. Administration acceptance was remarkably higher than prescription acceptance.

Ward round checklist improves patient perception of care.

BACKGROUND: Checklists have been shown to reduce morbidity and mortality in medicine by improving documentation and reducing errors. In the modern era of care, where patients are the centre of decision-making, this study examines patient perception of care and error prevention with the use of ward round checklist. METHODS: We conducted a prospective stepped-wedge cluster randomized controlled checklist intervention study using a standardized questionnaire to investigate patients' perception of ward rounds before and after implementation of a ward round checklist. RESULTS: A total of 124 patients completed the questionnaire. The overall percentage of items endorsed increased significantly by 5.1% from 64.8% to 70.0% (P = 0.014). Statistically significant improvements were seen in patients knowing their diagnosis (P = 0.027), the day's plan (P = 0.038), observing a medication chart (P < 0.001) and observation chart review (P = 0.008). CONCLUSION: Our study indicates that the use of a ward round checklist leads to patient-perceived improvements in aspects of quality of care.

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

BACKGROUND: Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety. OBJECTIVE: To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children's hospital that underwent root cause analysis and in which radiology was determined to play a contributing role. MATERIALS AND METHODS: All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities. RESULTS: In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (25%), followed by coordinating care and services (18.8%). The two most common key activities were interpreting/analyzing (21.9%) and coordinating activities (15.6%). CONCLUSION: Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children's hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology's direct and indirect contributions to patient harm.

A self-checking treatment couch coordinate calculation system in radiotherapy.

PURPOSE: Traditionally, the treatment couch coordinates (TCCs) for patients undergoing radiotherapy can only be determined at the time of treatment, placing pressure on the treating therapists and leaving several pathways for errors such as wrong-site treatment or wrong treatment table shift from a reference point. The purpose of this work is to propose an accurate, robust, and streamlined system that calculates TCC in advance. METHODS: The proposed system combines the advantages of two different calculation methods that use an indexed immobilization device. The first method uses an array of reference ball bearings (BBs) embedded in the CT scanner's couch-top. To obtain the patient-specific TCC, the spatial offset of the treatment planning isocenter from the reference BB is used. The second method performs a calculation using the one-to-one mapping relationship between the CT scanner's DICOM (Digital Imaging and Communications in Medicine) coordinate system and the TCC system. Both methods use a reference point in the CT coordinate system to correlate a point in the TCC system to perform the coordinate transfer between the two systems. Both methods were used to calculate the TCC and the results were checked against each other, creating an integrated workflow via automated self-checking. The accuracy of the calculation system was retrospectively evaluated with 275 patients, where the actual treatment position determined with cone-beam CT was used as a reference. RESULTS: An efficient workflow transparent to the therapists at both CT simulation and treatment was created. It works with any indexed immobilization device and can be universally applied to all treatment sites. The two methods had comparable accuracy, with 95% of the calculations within 3 mm. The inter-fraction variation was within ± 1.0 cm for 95% of the coordinates across all the treatment sites. CONCLUSIONS: A robust, accurate, and streamlined system was implemented to calculate TCCs in advance. It eases the pressure on the treating therapists, reduces patient setup time, and enhances the patient safety by preventing setup errors.

Análisis cognitivos de carga mental e identificación del error humano para mejorar la experiencia de usuario / Cognitive analyses of mental workload and human error identification for the improvement of user experience

Resumen Las personas, en ocasiones, pueden sentirse abrumadas al tratar de interactuar con la tecnología moderna. Ciertos productos de uso cotidiano cuentan con diseños deficientes, por lo que pueden provocar una experiencia insatisfactoria y frustración, produciéndose con ellas una carga mental en el usuario que pueda inducir al error. El uso de técnicas para la identificación del error humano y de la evaluación de carga mental en el diseño y evaluación de productos, puede proporcionar información relevante y útil, para mejorar la experiencia del usuario. El objetivo de este trabajo fue proponer una metodología para integrar la evaluación de carga mental y el análisis del error humano en el diseño de productos. Se evaluó la carga mental mediante la técnica perfil de carga de trabajo, Workload Profile (WP), y se utilizó una metodología de identificación del error humano, Task Analysis For Error Identification (TAFEI), en la configuración de audífonos inalámbricos. Diez usuarios participaron voluntariamente en el estudio; sus experiencias en el uso de los audífonos fueron videograbadas. Se utilizaron formularios para evaluar carga mental, y se identificaron errores humanos durante la etapa de configuración de los audífonos con el teléfono móvil. El método utilizado en este trabajo ofrece una mayor sensibilidad en la evaluación de la carga mental y permite determinar los recursos de atención que más se utilizan en la realización de la tarea. Se detectaron dos oportunidades de rediseño, una relacionada con la señal lumínica, y la otra para la identificación de las puntas para cada oído. A partir de los resultados de la aplicación de la metodología propuesta en este estudio, los diseñadores pueden mejorar la interacción entre las personas y los productos.

Abstract People can sometimes feel overwhelmed when trying to interact with modern technology. Some everyday products have deficient designs which can result in an unsatisfactory experience and even frustration. Additionally, they may produce a mental workload that can induce the user to make mistakes during their usage. The use of techniques for human error identification and mental load assessment in products evaluation and design can provide relevant and useful information to improve the user's experience. The objective of this work was to propose a methodology for integrating mental workload assessment and human error analysis into product design processes. In this work, mental workload was evaluated during the configuration of wireless earphones using the Workload Profile (WP) technique, and the Task Analysis for Error Identification (TAFEI). Ten users voluntarily participated in the study; their experiences during the use of mobile phone earphones were video recorded. Rating sheets were used to assess mental workload and human errors were identified during the earphones' setup stage with the mobile phone. The method employed for this research offers higher sensitivity in the assessment of mental workload. It also enables the identification of attention resources that were more frequently used during task completion. Two opportunities for redesign were identified. The first one is related to the light signal detection and the second one to the correct identification of ear tips. Conclusions and recommendations are given for designers to improve the interaction between people and products.

A Practical Guide to Performance Improvement: Failure Mode and Effects Analysis.

This article discusses the process of Failure Mode and Effects Analysis (FMEA) and how it relates to performance improvement (PI) and the development of high reliability organizations. As a proactive process, PI team members can use FMEA to identify and prioritize risk before errors occur in health care environments. This tool comprises steps to assess the failure risk of a process, system, or function before the failure occurs. Performance improvement team members can use FMEA as an additional tool to guide them when working to create a culture of safe patient care and improve patient outcomes. After reviewing this article, the reader should have a better understanding of FMEA, how to implement it, and how it supports PI processes and high reliability organizations. This is the fourth article of a six-part series about performance improvement.