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Use FMEA to examine the causes of heparin overdoses

Quality Improvement Report, November 1, 2008

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Despite increasing media coverage and awareness in the field, errors with heparin—sometimes fatal—are still making national headlines. Are these problems latent errors or conditions?

James Reason created the term “latent reason” to define a situation in which failures occur due to flaws in the design of a process rather than a specific error causing the failure; it is a scenario, such as lack of clarity or multiple processes, that allows more opportunity for errors to happen.

So the trick here is to find the cause of these errors and develop methods to prevent them. Let’s take a look at some of the various failure modes and causes at the root of heparin errors.

This is an excerpt from a member only article. To read the article in its entirety, please login.

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