Analysis of F ailure Modes in Cardiac Surgery Process using HFMEA Technique

An overview of the statistics published by various international organizations in various fields of health risk assessment، shows that medical errors (errors in diagnosis، prescription، treatment)، and system management in hospitals and medical centers have important roles in imposition of high costs and increasing rates of injury and death in the world. Heart disease، as the leading cause of death in industrialized countries and the second leading cause of death in Iran has always been a controversial topic for researchers in the treatment area. Due to the potential risk of this area، the occurrence of any error even small errors is a big risk that could ultimately endanger patients'' lives and incur costs to patients and hospitals. This paper attempted to identify، classify and evaluate the failures in open heart surgery using Healthcare Failure Mode and effect analysis (HFMEA) technique and present some solutions in order to control and reduce these failures. U sing the HFMEA، the open heart surgery process was reviewed and four processes، 22 sub-processes، and 82 activities، and 160 risks for these activities were extracted. Besides، the reasons of failures were determined and four failure modes were identified as the most important ones using qualitative and quantitative analysis and solutions were presented for them. Incomplete visit and injury of the saphenous nerve were extracted as the failure modes occurred due to inattention of examiner and incomplete examination and similarity of saphenous nerve and vessel causes injury of the saphenous. Tariff changes and the maneuvers of the second evaluator were proposed strategies to reduce failures mentioned before. Also wrong adaption of coronary with angiography and wrong estimation of the vessels length were two other identified failure modes. The lack of accurate angiography interpretation and carelessness of the surgeon and surgeon assisting in measuring the vessel’s length were the root causes of failures، respectively. Solutions such as performing angiography in multiple views and in a three-dimensional way (3D)، and also measuring the length of vessel using angiography were suggested solutions to reduce these failures. In open-heart surgery، such as inaccurate documentation، inadequate patient justification and lack of modern facilities to identify the precise and explicit situation seems obvious factors.