Applying Failure Mode Effects Analysis (FMEA) to Improve Choking Risk Prevention in a Mental Health Setting: Analysis Outcomes and Lessons Learned on Human Factors Collaboration

Abstract

This paper describes the collaborative work performed as part of a patient safety and quality improvement choking risk prevention initiative in a specialty mental health hospital in Ontario, Canada. In 2021, Ontario Shores Centre for Mental Health Sciences (Ontario Shores), in collaboration with the Healthcare Insurance Reciprocal of Canada (HIROC), conducted a Failure Modes and Effects Analysis (FMEA) to identify potential failure modes for their choking risk prevention process. “Failure modes” refer to states in a process that have the potential for unintended consequences. The interdisciplinary project team developed and validated a current-state process map, through which identified all opportunities for process improvement. A thematic analysis of the barriers revealed 14 distinct failure modes, each of which were rated along three scales (Severity, Occurrence, and Detectability) to form a ranked list based on Risk Priority Number. As part of a prospective analysis, several system-based and people-based mitigations were generated for each of the failure modes. As a result of the FMEA, Ontario Shores developed, and is in the process of, implementing a choking risk prevention and risk mitigation strategies action plan. In addition, the authors offer some reflections on the collaborative work between the two organizations, in recognition of the opportunity for healthcare organizations to benefit from human factors expertise and principles of applied safety science, usability engineering, and user-centered design.