MGH Department of Radiology - Quality Management and Education

PATIENT FOCUSED CARE

HFMEA
COMPLIANCE AUDIT

HFMEA

A Healthcare Failure Mode and Effect Analysis (HFMEA) is a proactive risk assessment of a high-risk or high-vulnerability area. It identifies and improves steps in a process thereby reasonably ensuring a safe and clinically desirable outcome.

The MGH department of Radiology through Quality Management and Education (QME) has conducted or is in the process of conducting HFMEAs for all of its modalities. Each Operations Manager, as the Team Leader, is expected to:

Choose the topic of the HFMEA for their modality
Identify team members to participate
Maintain notes and document the process
Develop a written summary
Present a PowerPoint presentation highlighting the process

QME guides the Team Leader by ensuring the process stays on track. QME is also responsible for all flowcharts.

Below is a list of the HFMEAs performed in the department and their current status:

Modality	Topic	Status
Bone Radiology (Yawkey Outpatient Center)	1. To reduce the number of potential patient emergencies. 2. To better prepare staff to respond to patient emergencies (a code or reactions: vasovagal, hypoglycemic, contrast) that may arise in the Yawkey Center for Outpatient Care, during a bone intervention exam.	Completed
Interventional Radiology	Minimizing the risk of radiation injury during high dose interventional procedures.	Completed
Magnetic Resonance Imaging	Keep ferrous metal out of the ED-MRI magnet.	Completed
Nuclear Cardiology	Identify and correct the failure points that lead to poor (improper) patient preparation before an exam.	Completed
Nuclear Medicine	Identify the failure points that lead to a patient being injected with the wrong radioisotope, the wrong patient being injected and imaged and/or errors in drug intervention (medication error).	Completed
Breast Imaging	To ensure that patients with BIRADS of either 0,3,4 or 5 return for their recommended follow-up exam or procedure.	Completed
Chelsea Health Center	Reduce the risk of potential injury to patients, staff and visitors, due to unsupervised young children, during a Radiology visit at Chelsea HC.	Completed
CT	To prevent the misadministration of IV contrast to outpatients.	Completed
ED	Appropriate safety monitoring of Inpatients on Ellison 2 during weekend hours, with a focus on two specific issues: 1. The monitoring of inpatients, on the weekends, before and after studies in the areas of Ellison 2 without direct visibility. 2.The definition of an emergency response process to accommodate the limited staffing pattern and the physical isolation of Ellison 2.	Completed
Ellison 2 (General Radiology)	To consistently complete the informed consent process and to provide quality patient care through proper patient identification and completion of the proper exam.	Completed
Ultrasound	Ensuring patient safety/patient monitoring in W2 holding area.	In Progress
3D Lab	To ensure the 3D Lab billing practices are Medicare compliant.	Completed
MGH Imaging Chelsea	To prevent unauthorized access to MRI Magnet	In Progress
MGH West Waltham	To ensure employee safety during late night and weekend working hours	In Progress

COMPLIANCE AUDIT
Information: Pavel Rabiner

QME ensures the department’s compliance with department and Joint Commission policies including: