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HYPOTHESIS: Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures. DESIGN: Failure mode and effect analysis. SETTING: Academic research. PARTICIPANTS: A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled. MAIN OUTCOME MEASURES: A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree. RESULTS: The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes. CONCLUSIONS: Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.

Original publication




Journal article


Arch Surg

Publication Date





582 - 588


Continuity of Patient Care, Evaluation Studies as Topic, Female, Humans, Interdisciplinary Communication, Interprofessional Relations, Male, Medical Errors, Patient Care Team, Postoperative Care, Preoperative Care, Risk Assessment, Safety Management, Surgery Department, Hospital, Surgical Procedures, Operative, Systems Analysis, Total Quality Management, Treatment Outcome