Implementing the Joint Commission Requirements on FMEA

Key Takeaway:

The Joint Commission issues requirements for member hospitals to conduct Failure Modes and Effects Analysis (FMEA). This is a fairly detailed list of requirements, and healthcare organizations have to adhere to them to ensure better quality patient outcomes.

Healthcare Failure Modes and Effects Analysis (FMEA) is considered an important tool for evaluating the risk of patient injury. It is a popular proactive and preventive technique that can be used to gauge the risk of patient injury before it happens. Its approach is to prospectively identify and prioritize potential failures in the system. Because it takes this route; this method is considered relatively comprehensive.

The Joint Commission requirements on FMEA

Requirements for conducting FMEA by healthcare providers are spelt out by the Joint Commission. The Joint Commission is tasked with accrediting hospitals. The core requirement is that each member hospital needs to select a minimum of one process that can be considered high risk, each year. It has to perform proactive risk assessment on this process each year. These are spelt out in what the FMEA codifies as Requirement LD.5.2.

Some more details of the Joint Commission requirements on FMEA

Joint Commission requirements on FMEA are quite detailed and are set out in clear terms. These are the salient Joint Commission requirements on FMEA:

  • Selection of the risk based process has to be mainly but not fully based, on information that the Joint Commission publishes, in which the most commonly occurring kinds of what are called "sentinel events", as well as patient safety risk factors are identified
  • Leadership in member hospitals has to define and implement a program for identifying risks to patient safety and reducing medical/health care errors. This program has to be ongoing and proactive.
  • The common processes involving risks or possibly leading to sentinel events are: medication use, use of blood and blood components, operative and other procedures, seclusion, restraint use -a part of care care/services provided to high-risk populations, and resuscitation.

Steps to conducting FMEA

The Joint Commission requirements require each member hospital to carry out an FMEA based on the following steps:

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