Study on RCA and HFMEA in Patient Safety with Measurable Outcomes: A Case Scenario

Abstract

Introduction: Safety concerns of outborn neonatal infant babies during transportation to the NICU had been a concern. Better team coordination and improvement in the technical competency of the care providers helped implement the ambulance policy. Methods: With the background of the Donabedian model and Juran's Trilogy concepts, process improvisation was performed. The RCA (Root Cause Analysis) and HFMEA (Healthcare Failure Mode and Effects Analysis) as tools were used for better deliverables. Results: The measurable outcomes in terms of time taken for departure before and after were compared, which showed considerable significance. By measuring the baby temperatures, a significant difference was seen in clinical aspects. Discussion: Lack of infrastructure, equipment for neonatal transportation was a challenge that required prioritization of budget allocation. The procurement policy of equipment had to be relooked for user-friendly strategies. Lack of trained staff and doctors, which were major issues, required an intense training and development module. The challenges of hypothermia, ventilation issues during transportation of neonates were of major concern, were tackled using quality tools. Application: To minimize the mortality and morbidity of neonates, infants by Specialized Pediatric Critical Care Transport (SPCCT) ambulance policy was implemented. The value addition was to minimize the risks and prevention of hazards. Conclusion: Improvement in the Technical competency of nurses and caregivers was observed. Nurses were well exposed to handling transporting sick babies. Logistics, equipment handling was performed properly.  With better team coordination, the babies were safe. The trust and confidence among the members of the community at large improved. The patient footfall increased in numbers.