NUR 683 Module 4 Failure Mode Analysis Paper Example

Where Barcode Scanning Breaks Down: A Prospective Risk Analysis on a Telemetry Unit

[Student Name]

Southern New Hampshire University

NUR 683: Patient Safety and Quality Capstone

Module Four Failure Mode Analysis Paper

[Instructor Name]

[Date]

Where Barcode Scanning Breaks Down: A Prospective Risk Analysis on a Telemetry Unit

Root cause analysis looks backward after harm. Failure mode and effect analysis looks forward, asking how a process could fail, what would happen if it did and which failures deserve attention first. Baseline observation on the Ridgeview telemetry floor found that both the patient and the medication were scanned in only 79% of administrations. This paper reports a prospective analysis of barcode medication administration on the unit, explains the method, presents the process map and hazard scores, compares the findings with published research on workarounds and proposes actions with owners and measures.

The Method

DeRosier et al. (2002) describe the Healthcare Failure Mode and Effect Analysis built at the VA's patient safety center, which borrowed engineering methods to clinical care. The approach has five steps: choose a high-risk process and define its scope; gather a team that includes people who do the work and at least one person unfamiliar with it; draw the process as a flow diagram; identify ways each step can fail and score them; and settle on fixes along with the numbers that will reveal if those fixes held.

Scoring combines severity, rated from minor to catastrophic, with probability, rated from remote to frequent, each on a four-point scale. Multiplying the two gives a hazard score, and failure modes scoring 8 or more pass to a decision tree. Its three questions are simple: would failure of this one step alone cause harm, is there already a safeguard that reliably works and would anyone notice the problem before it reached the patient? Only failure modes that survive the tree proceed to action planning, which keeps the team focused on genuine risks.

Team and Process Map

The team included two day-shift nurses, one night-shift nurse, a pharmacist, an informatics nurse, a biomedical engineer who maintains the scanners and a respiratory therapist who had never given medications on the unit and could ask naive questions. The team met four times for ninety minutes.

The process was mapped in eight steps: the order is verified by pharmacy; the medication is removed from the dispensing cabinet; the nurse takes it to the room; the nurse scans the patient's wristband; the nurse scans the medication; the system checks the match and displays alerts; the nurse gives the dose; and the administration is documented. For each step the team listed possible failure modes, drawing on the baseline observation, recent reports and their own experience.

Hazard Analysis

The team identified 19 failure modes, of which six scored 8 or higher. Table 1 shows those six with their scores and the outcome of the decision tree. The highest-scoring failures clustered around the scanning steps. Wristbands printed on the old label stock smudged and would not scan after a shower, which led nurses to scan a spare band kept on the computer cart. Rooms without wall-mounted scanners led nurses to scan at the doorway before walking to the bedside, or to give the dose and scan afterward. Alerts for a wrong dose appeared in small text among routine warnings and were overridden without reading. Weak wireless coverage in two rooms caused the scanner to freeze.

Table 1. Failure Modes Scoring 8 or Higher

Note. Severity and probability use the four-point scales of the method.

Comparison with Published Workarounds

The team's findings closely match what Koppel et al. (2008) documented across several hospitals. Through observation, interviews and review of override logs, they described many kinds of workarounds, such as scanning wristbands attached to carts or doorframes, scanning a medication after giving it and overriding alerts in bulk, and they traced these to a wide range of causes, including unreadable labels, malfunctioning scanners, failing batteries, poor wireless coverage and pressure to move quickly. Their central point was that workarounds are usually rational responses to poorly designed systems, not simple noncompliance.

That point matters for the capstone. If the unit responded to low scanning rates by disciplining nurses, it would treat the symptoms while leaving the causes in place. The analysis instead identifies label stock, scanner placement, wireless coverage and alert design as the latent conditions to fix.

Why Full Scanning Matters

Poon et al. (2010) compared units before and after barcode verification was introduced with an electronic administration record and found substantial reductions in administration errors other than timing errors and in potential adverse drug events. The protection depends on every patient and every dose being scanned at the bedside. A spare wristband on a cart or a dose scanned after administration defeats the check entirely while still producing a record that looks compliant, which is why these failure modes scored highest.

Actions and Measures

For each failure mode, the team chose actions that change the system rather than rely on reminders. Spare wristbands will be removed from carts, and the pharmacy will stock durable, smudge-resistant label stock, owned by the nurse manager and the supply chain lead. Wall-mounted scanners will be installed in the remaining rooms, owned by biomedical engineering. Informatics will redesign wrong-dose alerts to appear as a hard stop requiring a reason. The two low-signal rooms will receive wireless boosters. The interruption between scanning and giving a dose will be addressed by the capstone's interruption bundle. Outcome measures are full scanning rate by room, override rate for wrong-dose alerts and scans recorded after the documented administration time, each reviewed monthly.

Conclusion

The analysis shows that low scanning rates on the unit arise from predictable weaknesses in labels, equipment, alerts and connectivity, not from indifference. Fixing these conditions, together with protecting the moment between scan and administration, gives the capstone intervention a clear technical foundation.

References

DeRosier, J., Stalhandske, E., Bagian, J. P., & Nudell, T. (2002). Using health care failure mode and effect analysis: The VA National Center for Patient Safety's prospective risk analysis system. The Joint Commission Journal on Quality Improvement, 28(5), 248-267. https://doi.org/10.1016/S1070-3241(02)28025-6

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115