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Failure Mode Effects Analysis (FMEA)Associated with Implementation of CDS tool into CPOE

1 Process Step Right information – implement CDS alert tool into CPOE that utilizes evidence based and best practice data

2 Potential Failure Mode CDS tool does not reflect Creation of inefficient workflow CDS tool is outdated
current best practice guidelines potentiating errors
increasing patient safety issues

3 Potential Cause(s) Difficulty incorporating Lack of customization of CDS Lack of resources to maintain and
extensive quantity of research tool to support the user needs update the CDS tool to reflect
being published on an ongoing current needs and guidelines
basis

4 Severity 3 5 5

5 Probability Uncommon Frequent Uncommon

Process Step #1

6 Hazard Score 2 8 4

7 Action (Eliminate, Control, or Accept Control Control

Accept)
8 Description of Action -There will always be new -The CDS tool should be -Foresight when implementing the
research and guidelines customized to reflect current CDS tool should include planning
emerging that cannot be safety issues for future upgrades and making sure
immediately incorporated into -CPOE users should be involved the resources required are available
the CDS tool. in building the CDS tool to -The effectiveness of the tool in
-Current best practice guidelines support creation of an intuitive improving clinician workflow and
should be utilized upon rollout tool patient safety can result in more
of the CDS tool. -Minimizing workflow available resources e.g. cost savings
-Future updates can be made on interruptions by using a tier from patient safety events can be
a later basis which will system for alerts or notifications utilized to upgrade the tool.
incorporate newer research and will eliminate alert fatigue. - If resources to maintain the tool are
guidelines. not available and renders it to be
inefficient and not meeting the set
objectives, then the CDS tool should
be rescinded.
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1 Process Step Right people – inform physicians on benefits of CDS tool and how to incorporate it into their decision
making

2 Potential Failure Mode Workarounds/deviations from Pushback and conscious decision Increased patient safety events from
best practice that can lead to not to use CDS tool which can implementing a CDS tool without
patient harm lead to patient harm established goals or objectives
3 Potential Cause(s) Resistance from physicians to Lack of user involvement in the Lack of clear goals and objectives of
change/ lack of buy-in design and implementation using CDS tool
process

4 Severity 5 5 3
Process Step #2

5 Probability Occasional Frequent Occasional

6 Hazard Score 6 8 3

7 Action (Eliminate, Control, or Control Control Eliminate

Accept)
8 Description of Action -Ongoing training -Elicit user feedback -CPOE users should be involved in
-Elicit user feedback -Involve CPOE users in the building the CDS tool and
-Use peer influence to support development, implementation establishing the goals and objectives
for the tool and future updates of the CDS -CDS tool should be customized to
tool to foster a sense of reflect current safety needs that
ownership require improvement
- Utilize super-users who can -Ongoing training will help reeducate
influence their coworkers to users on the goals and objectives of
avoid conscious deviation from the tool
adherence to using an evidence-
based tool
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1 Process Step Right intervention format – Use customized EHR alert thresholds or tier system i.e. passive, soft and hard
stop alerts

2 Potential Failure Mode Ignoring critical notifications Delay in care Overriding alerts for critical issues can
that can lead to patient harm lead to patient harm

3 Potential Cause(s) Desensitization to critical alerts Increase in time-to-order and Lack of customizing alerts to
from low-priority notifications time-to-completion for specified distinguish simple reminders or
tasks notifications from critical ones

4 Severity 6 7 6
Process Step #3

5 Probability Frequent Frequent Frequent

6 Hazard Score 8 12 8

7 Action (Eliminate, Control, or Control Control Control

Accept)
8 Description of Action -Use a tier system and -Monitor the efficiency of the -Ongoing training to educate CPOE
customize alerts/notifications to tool to make improvements that users on usage of the CDS tool to
the degree of criticality to help support more efficient patient support informed decision-making
decrease alert fatigue and management -Use a tier system to customize
desensitization -Customize notifications to notifications to the degree of criticality
-Improve the CPOE interface to lessen workflow interruptions -Monitor the tool to determine which
support features that do not -User feedback will help alerts are commonly overridden to
interrupt workflow determine how the tool can be revise or improve on the notification
-Elicit user feedback to improve improved to support task
the tool completion and efficiency
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1 Process Step
Right monitoring tool – CPOE CDS tool evaluation

2 Potential Failure Mode Users not utilizing CDS tool to CDS tool does not reflect user Lack of buy-in from users who choose
improve patient safety needs and therefore does not not to use the CDS tool potentially
promote patient safety negating patient safety
3 Potential Cause(s) Lack of user feedback Lack of specific goals and Different visions or ideas on the
objectives during CDS tool function of the CDS tool
implementation
4 Severity 4 4 4
Process Step #4

5 Probability Occasional Occasional Frequent

6 Hazard Score 3 3 4

7 Action (Eliminate, Control, or Control Control Control

Accept)
8 Description of Action -Eliciting user feedback on an -Monitor effectiveness of the tool -Involve the CPOE users in the CDS
ongoing basis on current patient safety tool development and updates to help
- Ongoing training on the goals -Elicit user feedback to promote buy-in of the tool
and objectives customize the tool -Use super-users to provide peer
-Utilizing super-users to provide -Create user friendly and influence
peer influence intuitive workflow with -Ongoing training and user feedback
customized alerts
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1 Process Step Right maintenance of CDS tool – Regular upgrades to reflect specific needs and best practice

2 Potential Failure Mode CDS tool does not reflect Users reject CDS tool potentially CDS tool upgrade does not reflect
specific needs or best practice increasing patient safety events ongoing user needs and negates
that supports patient safety improving patient safety
3 Potential Cause(s) Inadequate resources Change resistance from too many Poor user feedback and inefficient
or constant updates monitoring of CDS tool negates
making worthwhile updates
4 Severity 7 6 4

5 Probability Frequent Occasional Occasional

Process Step #5

6 Hazard Score 12 6 6

7 Action (Eliminate, Control, or Eliminate Control Control

Accept)
8 Description of Action -Monitor tool effectiveness on -Elicit user feedback to -Provide a variety of feedback tools
patient safety determine areas requiring e.g. anonymous report or peer
-Perform regular updates improvement discussion, to elicit adequate response
incorporating user feedback and -Involve users in maintaining the -Monitor CDS tool effect on patient
patient safety needs tool can help determine the ideal safety events and initial goals and
-If the CDS tool does not reflect frequency of updates to avoid objectives
best practice and does not information overload -Utilize CPOE users in making
support current patient safety -Provide ongoing training changes to the tool
issues and resources remain sessions that are easily
unavailable, then the tool should accessible, brief and concise
be rescinded.