Submission Type

Original Research


Introduction: In March 2020, in response to the COVID-19 pandemic, an interprofessional, interdisciplinary team at Maine Medical Center used Healthcare Failure Mode and Effect Analysis (HFMEA) and in situ simulation to rapidly identify and mitigate latent safety threats (LST) in patient transport protocols.

Methods: Following HFMEA steps, stakeholders representing a variety of disciplines assembled to address transport of patients with COVID-19. A process map was created to describe the process. With hazard analysis using table-top simulation followed by in situ simulation, we identified, categorized, and scored LSTs. Mitigation strategies were identified during structured debriefing.

Results: Fourteen LSTs were identified in the categories of infection prevention (4), care coordination (2), equipment (2), facilities (2), teams (2), clinical skills (1), and diagnosis and treatment (1). Of these, 10 had “critical” hazard scores. Mitigation solutions were tested with in situ simulation. Results were shared with leadership and led to changes in hospital-wide protocols.

Discussion: The COVID-19 pandemic presented an urgent need to create or adapt protocols to keep patients and staff safe. Our team combined simulation with HFMEA methodology to improve the safety of protocols for transporting patients with COVID-19. Simulation enabled recreation of real-world experience that exposed LSTs more thoroughly than mental walkthroughs alone. Use of HFMEA methodology supported quantifying identified LSTs and proposing mitigation strategies, while in situ simulation facilitated testing many proposed strategies.

Conclusions: HFMEA used with in situ simulation provides an effective method to efficiently and thoroughly probe a process for failure modes, providing practical mitigation strategies.



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