Using risk analysis to ensure patients’ medication safety during hospital relocations and evacuations

Abstract

Objectives

To ensure patient safety and the preparedness of medication processes during hospital relocations and evacuations by using Failure Modes, Effects, and Criticality Analysis (FMECA).

Methods

The relocation of six regional hospitals to a single building, resulting in 400 beds being moved, could be compared with an emergency evacuation. An FMECA was performed on the hospital group’s internal medicine and intensive care units (IMU and ICU), examining how medication processes would be affected by a hospital relocation or evacuation.

Results

We identified 59 hospital relocation and 68 evacuation failure modes. Failure modes were ranked based on their criticality index (CI; range 1–810). The higher the CI, the greater the patient-related risk. Average initial IMU and ICU hospital relocation CI scores were 160 (range 105–294) and 201 (range 125–343), respectively, subsequently reduced to 32 (−80%) and 49 (−76%) after mitigation measures. Average initial IMU and ICU evacuation CI scores were 319 (range 245–504) and 592 (range 441–810), respectively, subsequently reduced to 194 (−39%) and 282 (−52%). Most mitigation measures (17/22), such as for example checklists, could be implemented in both situations. Due to their unpredictable nature, five measures were specific to evacuation situations.

Conclusions

This study highlights the value of using an FMECA on medication processes to anticipate potential negative impacts on patient safety during hospital relocations or evacuations. Preparation for a hospital relocation can provide useful knowledge and an opportunity to test mitigation measures that might prove useful in evacuations.

Introduction

Since the Institute of Medicine’s 2000 report entitled “To Err is Human”,¹ the concept and development of a culture of patient safety has become a major healthcare topic, widely covered in the literature. Healthcare services have become committed to patient safety in all contexts. Although many hospital wards have applied risk management approaches to reduce risks for patients, these have yet to be generalised to the majority of activities performed in healthcare environments.² Preparedness is essential to improving reactions during crises and thus reducing any potential negative consequences for patients. Healthcare professionals (HCPs) and support staff are encouraged to be better prepared and to create and practise standard operating procedures for evacuations before they need to be used.^{3 4}

Hospital relocations or evacuations are complex—often unique—events and thus inherently hazardous to patient safety. Specific risk management approaches and a certain level of preparedness must be planned to reduce the probability of adverse events.^3–6 Few studies in the literature have underlined the need for specific tools and preparedness for hospital relocations or moving a ward.^7–13 Duffy et al reported how the relocation of a 525-bed acute tertiary hospital in Australia was postponed when a risk analysis revealed that the new building was not ready.⁵ Schaufele and Rozenfeld et al agreed that a hospital relocation was a complex task that should be planned for similarly to disaster response planning.^{14 15} They developed specific tools and operational techniques that could be used in the event of a disaster, a need for surge capacity or relocation to another facility. They saw a hospital relocation as an opportunity to help other healthcare facilities better prepare for safely and efficiently evacuating their patients. Other authors have described incident command teams, planning for a 48-hour census reduction, and performing simulations and debriefing sessions.^{9 15 16} These experiences were reported as lessons learnt after relocations, but they included no prospective risk analyses that could have been used to develop standardised tools. The variations in setting, operation and architecture across different types of hospitals and clinical wards also make it difficult to apply a ‘one-size-fits-all’ solution. This highlights the need for prospective targeted strategies to ensure patient safety during unique events like emergency evacuation or relocation.²

Another risk to patient safety in hospitals is related to medication errors. Many report the impact of this risk—missed medication doses, administration errors and others^17–19—raising associated costs to USD 42 billion.²⁰ Despite this, we found no analyses of medication processes during relocation situations in the literature.²¹

Our 400-bed hospital group located in Switzerland had various units (six general medicine, five surgical, two paediatrics including neonatology, three intensive care, two gynaecology and obstetrics, and three rehabilitation wards) spread across six different sites (maximum ~20 km apart or ~20 min driving time). In November 2019, all six sites were relocated to a single new building within 1 month of one another. Such a massive operation required the development of versatile tools and strategies to ensure patient safety. Failure Modes, Effects, and Criticality Analysis (FMECA) is a systematic prospective tool for analysing and reducing the risks of complex activities. It is based on the proactive structured analysis of processes by a multidisciplinary team. The objective is to improve the quality and safety of those processes using an iterative approach.²² It has already been used successfully to perform observational analytical studies of medication management processes^23–25 and to evaluate risks within hospital wards, but never in relocation or evacuation situations.^{5 26 27}

The objective of the present study was to prospectively perform an FMECA on medication processes to identify patient-related risks in the context of our upcoming hospital relocation. This would enable us to propose mitigation measures to increase patient safety in two specific situations: hospital relocations and evacuations.

Methods

Failure Modes, Effects, and Criticality Analysis (FMECA)

After management approval, an FMECA was performed on our hospital’s internal medicine and intensive care units (IMU and ICU). A multidisciplinary team of 12 IMU and ICU specialists was composed of a physician, a nurse and a head nurse from each unit, two pharmacists, a logistics manager, a member of the management team, a representative of the patient safety board and a specialist in FMECA. Three meetings were organised. The first meeting involved the entire team for over 3 hours as it reviewed initial medication processes—applicable to both hospital relocation and evacuation situations—and determined failure modes. The criticality analysis, performed at the second meeting, and the safety improvement analysis, performed at the third meeting, were completed in under 2 hours in total by their respective IMU and ICU specialists. The pharmacists, logistics manager, management team member, patient safety board representative and the specialist in FMECA methodology participated in all meetings. As this type of analysis is not considered to be a clinical trial in Switzerland, it only required approval by our Institutional Review Board.

Determination of failure modes

First, the overall high-level medication process was broken down into substeps (figure 1), and a subsequent brainstorming session determined the potential failure modes in the context of a hospital relocation. Each participant worked individually to determine potential failure modes and their causes based on their professional knowledge. The moderator aggregated similar topics on an FMECA worksheet, and then a team analysed and discussed all the propositions in order to finalise a list of failure modes and their causes. In a similar approach, the team added specific potential emergency evacuation failure modes.

Figure 1.

Hospital relocation scenario with initial substeps (up) and the substeps with proposed mitigation measures (down), in blue. D−n, day of departure minus n days.

Criticality analysis

Each failure mode’s criticality index (CI) score was calculated by multiplying its occurrence, severity and detection scores. Its likelihood of occurrence was rated from 1 to 10 and its potential severity to patients and the chance of detecting it before it affected patient safety were rated from 1 to 9, based on the grid published by Williams and Talley.²² Rating estimations of all the failure modes were obtained by team consensus, considering the specific environments in which hospital relocations or evacuations might take place.

Safety improvement analysis

Failure modes were prioritised based on their CI scores (minimum 1–maximum 810). Pareto’s principle (or the 80/20 rule) was applied to select the failure modes with the greatest potential impact (the 20% with the highest CI scores). The team discussed and proposed mitigation measures for each failure mode above the threshold. It then evaluated each improvement by considering feasibility and costs. Based on the hypothetical implementation of all the proposed mitigation measures, a second CI score was calculated to evaluate their impact.

Results

Determination of failure modes

The higher-level medication process consisted of three steps: departure from the old site of Hospital A, Transport and installation at the new site of Hospital B. This process was broken down into nine subtasks (figure 1). Failure modes were only sought afterwards, with 59 linked to a hospital relocation and 68 linked to an evacuation of both the IMU and ICU.

Criticality index analysis

The sum of the IMU’s CI was 4412 for a hospital relocation and 11 732 for an evacuation. These values are well below the maximum sum that could have been attained. Indeed, if all CI scores were of maximum criticality (810), the total sum would have been 55 080. On the other hand, if they were all minimal, the sum would have been 68. The highest IMU subtask CI scores for a hospital relocation or evacuation process were 294 and 504, respectively, and these risks both related to losses of information about patient medication. The mean initial CI score for the IMU’s relocation subtasks was 160 (range 105–294). The mean initial CI score for the IMU’s evacuation subtasks was 319 (range 245–504).

The sum of the ICU’s CI was 4526 for hospital relocation and 18 770 for an evacuation (the minimum possible was 59 and the maximum was 47 790). The highest ICU subtask CI scores for a hospital relocation or evacuation process were 343 and 810, respectively, and these risks related to the impossibility of correctly restarting treatment at the new hospital due to lack of training or equipment (for the hospital relocation) and the impossibility of caring for patients either during their transport or at the new site due to a lack of medication (for the evacuation). The mean initial CI for ICU hospital relocation subtasks was 201 (range 125–343). The mean initial CI for ICU evacuation subtasks was 592 (range 441–810).

Figure 2 shows the mean CIs for IMU and ICU subtasks in the hospital relocation and evacuation situations.

Figure 2.

Mean criticality index (CI) scores for hospital relocation (A) and evacuation (B) scenarios for the Intensive Care Unit (ICU) and the Internal Medicine Unit (IMU) in the nine substeps identified in figure 1.

Safety improvement analysis

Following Pareto’s principle, 12 hospital relocation and 14 evacuation failure modes were selected. Pareto’s principle suggests that 80% of the effects are the product of 20% of the causes. In our case, it was used to identify the 20% of the most important failures in order to decrease 80% of the risks for patients. Tables 1 and 2 show failure modes with their causes, their CI and their mitigation measures, and table 3 describes the mitigation measures in more detail. Six groups of mitigation measures were proposed for reducing the risks related to medication processes in hospital relocation and evacuation situations. IMU mitigation measures reduced the mean CI score of the selected failure modes from 160 to 32 (−80%) for hospital relocations and from 319 to 194 (−38%) for evacuations. ICU mitigation measures reduced the mean CI score from 201 to 49 (−76%) for hospital relocations and from 592 to 282 (−52%) for evacuations.

Table 1.

Failure modes with their causes, mitigation measures and criticality index (CI) scores for internal medicine unit (IMU)

Step	Failure modes	Cause(s)	Hospital relocations				Evacuations
			Mitigation measures	CIa	CIb	∆	Mitigation measures	CIa	CIb	∆
Hospital A (departure from old site)	Issues surrounding medication preparation (dose, administration mode, mode of conservation)	Human error, lack of communication	Checklist (Medication handling and Medical visit sections) IMU patient moved without regular medication Prescription verified by pharmacy technician Pharmacist available for drug management	180	105	−42%	Essential medication, antidotes and emergency drugs bags Emergency evacuation kit	315	210	−33%
	Patient not treated since arriving at hospital (night-time admission)	Patient’s health not suited to transfer	Pharmacist available for drug management Checklist (Medication handling and Medical visit sections)	120	20	−83%	Checklist (Medication handling and Tracking and transmission sections) Triage algorithm Essential medication is available at all times	343	245	−29%
	Patient not in the IMU or forgotten in the case of an emergency evacuation	Logistical and communication issues					Fail-safe mode available Tracking	343	175	−49%
	No identification 'bracelet' during medical examination	Logistical and communication issues					Fail-safe mode available Checklist	343	175	−49%
	Treatment without consideration of new orders from the pre-transport medical examination	No verification of treatment modifications	Checklist (Medication handling, Medical examination, and Tracking and transmission sections)	196	24	−88%	Fail-safe mode available Checklist (Medication handling and tracking and transmission sections)	392	210	−46%
	Medication incorrectly conditioned	Medication handled or stored incorrectly	Prescription verified by pharmacy technician Pharmacist available for drug management IMU patients moved without their usual medication	105	12	−89%
	Medication not updated following new prescriptions from the departure medical examination	Patient’s computerised medical file not updated	Checklist (Medication handling, Medical examination, and Tracking and transmission sections)	168	24	−86%
	Mismatch between patient’s treatments	Human error, lack of communication	Checklist (Medication handling, Medical examination, and Tracking and transmission sections) Specific medication transported with the patient, tracked and sealed	150	20	−87%	Fail-safe mode available Checklist (Medication handling and Tracking and transmission sections) Tracking patient ID and localization	245	150	−39%
Transport	Administration of medication not correctly tracked during transportation	Human error, lack of communication	Checklist (Medication handling, Tracking and transmission sections) Specific medication transported with the patient, tracked and sealed IMU patients move without their usual medication	200	20	−90%
	No treatment available	Contextual pathology (eg, fractures, burns)					AMP Emergency drugs bag Emergency evacuation kit	294	245	−17%
	No treatment available	Logistical and communication issues					AMP Emergency drugs bag Emergency evacuation kit	280	120	−57%
Hospital B (installation at new site)	Medications already administered	Lack of medication traceability	Checklist (Medication handling, Medical examination, and Tracking and transmission sections) Specific medications transported with the patient, tracked and sealed IMU patients moved without their usual medication	120	12	−89%
	Impossibility of giving medication to patient	Incompatible means of administration	Essential medication available at all times Specific transport team designated according to initial triage (including special supervision by HCPs if required by patient) Checklist (Tracking and transmission section)	120	12	−89%
	No access to emergency medication	Logistical and communication issue					AMP Emergency drugs bag Emergency evacuation kit	336	245	−27%
Global	Patient feels unwell during intra-hospital transfer, but no qualified HCPs present to assist	Lack of qualified staff	Essential medication available at all times Specific transport team given initial triage assigned Reanimation team available (phone number known) Checklist (Medication handling and Medical examination sections) Tracking patient ID and localisation	147	42	−71%	Emergency call-back mode AMP Emergency evacuation kit	252	140	−44%
	Impossibility of correctly ensuring delivery of the patient’s medication	Workload too high (transfer, new admissions, not enough staff)	Essential medication available at all times Specific transport team given initial triage assigned Specific medication transported with the patient, tracked and sealed Checklist (Medication handling section) Automated medication dispensing system	120	20	−83%	Emergency call-back mode AMP Emergency evacuation kit	280	168	−40%
	Loss of information about the patient’s treatment/medication	Communication issues	Transmission protocol Checklist (Medication handling, Medical examination, Tracking and transmission sections) Prescription verified by pharmacy technician Pharmacist available for drug management	294	42	−86%	Checklist (Medication handling and Tracking and transmission sections) Fail-safe mode available	504	245	−51%
Mean				160	32	−80%		319	194	−39%

AMP, Advanced Medical Post; HCPs, Healthcare professionals; ID, Identity.

Table 2.

Failure modes with their causes, mitigation measures and criticality index (CI) scores for intensive care unit (ICU)

Step	Failure modes	Cause(s)	Hospital relocation				Evacuations
			Mitigation measures	CIa	CIb	∆	Mitigation measures	CIa	CIb	∆
Transport	No treatment available due to contextual pathology during transport	Contextual pathology (eg, fractures, burns)					AMP Vital medications, antidotes and emergency drugs bags Emergency evacuation kit	810	225	−72%
	No treatment during transfer due to lack of medication	Logistical and communication issues	Checklist (Medication handling, Medical examination, Tracking and transmission sections) Specific medication transported with the patient, tracked and sealed Transmission protocol	162	18	−89%	AMP Vital medications, antidotes and emergency drugs bags Emergency evacuation kit	486	225	−54%
	Medication administration during the transfer not correctly tracked	Human error, lack of communication	Checklist (Medication handling, Tracking and transmission sections) Transmission protocol	160	20	−88%	Vital medications, antidotes and emergency drug bags Emergency evacuation kit	441	225	−49%
	Batteries not charged, not enough equipment, lack of oxygen	Logistical issues	Checklist (Tracking and transmission sections)	135	9	−93%
Hospital B (installation at new site)	Patient transported to the wrong place	Communication issues					Tracking patient ID and localization Degraded mode available Transmission protocol	560	252	−55%
	Double-dose or medication not administered	Lack of medication traceability	Checklist (Medication handling, Tracking and transmission sections)	175	28	−84%
	Impossibility of providing treatment due to incompatible administration equipment	Lack of training and compatibility issues	Reanimation team available Specific transport team given the initial triage assigned Transmission protocol	343	105	−69%
	Impossibility of accessing the required medication	Lack of medication (no stock of the drug in the hospital), delivery/order issues	Checklist (Medication handling, Medical examination, Tracking and transmission sections) Specific medication transported with the patient, tracked and sealed Transmission protocol Prescription verified by pharmacy technician Automated medication dispensing system	175	28	−84%	AMP Vital medications, antidotes and emergency drugs bags Emergency evacuation kit	810	225	−72%
Global	Patient feeling unwell during intra-hospital transfer, but no qualified HCPs present to assist	Lack of qualified staff	Transmission protocol Checklist (Medication handling, Medical examination, Tracking and transmission sections) Vital medication is available at all times Triage algorithm Reanimation team available Specific transport team	216	32	−85%	AMP Vital medications, antidotes, and emergency drugs bags Emergency evacuation kit Emergency call-back mode	567	378	−33%
	Impossibility of correctly ensuring delivery of patient’s medication in the contextual environment	Too high workload (transfer, new admissions, not enough staff)	Transmission protocol Checklist (Medication handling, Medical examination, Tracking and transmission sections) Vital medication available at all times Triage algorithm Reanimation team available Specific transport team given the initial triage assigned	120	20	−83%	AMP Vital medications, antidotes and emergency drugs bags Emergency evacuation kit Emergency call-back mode	630	294	−53%
	Loss of information about the patient’s treatment/medication	Communication issues	Transmission protocol Checklist (Medication handling section) Patient’s information (informatic folder or degraded mode)	320	120	−63%	Emergency evacuation kit	560	252	−55%
Mean				201	49	−76%		592	282	−52%

AMP, Advanced Medical Post; HCPs, Healthcare professionals; ID, Identity.

Table 3.

Mitigation measures for Intensive Care Units (ICUs) and Internal Medicine Units (IMUs) during hospital relocations or evacuations

Groups	Mitigation measures	No of failure modes affected
Departure medical examination protocol	Triage algorithm (checkpoints, mode of transport)	3
	Checklist (treatment modification, departure decision traceability)	15
Tracking and transmission tools	Transmission protocol (doctor, nurse and transport team; same team at the departure and the day before; in addition, departure staff should gradually arrive with patients at the new site)	9
	Tracking (patient’s identification and localisation)	4
	Checklist (equipment, transmission process, medication tracking, annotation, specific to a patient, follow patient, checkpoints)	19
Medication handling protocol	Specific medications transported with the patient, tracked and sealed	6
	Vital medication available at all times	14
	IMU patients moved without their regular medication	4
	Checklist (medication administration monitoring, specific medication tracking, print patient’s medication list)	21
Technical and human support	Resuscitation team available at departure and arrival sites	4
	Pharmacy hotline available 24 hours/day	4
	Medication checked by pharmacy technician at departure hospital and on arrival at new hospital site	3
	Medical dispensing specialist available at the new hospital	2
	Specific transport team given initial triage algorithm (patient(s), patient(s)/nurse, patient(s)/nurse/doctor)	6
Additional evacuation preparedness	Emergency evacuation kit (eg, evacuation plan, checklist)	14
	Advanced Medical Post available and staff aware of it	10
	Vital medication, antidotes and emergency drugs bags	16
	Emergency call-back mode	4
	Fail-safe mode available and tested (eg, electronic patient records)	5
Training	Inform staff about risks and mitigation measures and describe the 'Move' day (e-learning, newsletters)	Overarching mitigation measures
	Training on the tools developed (checklists, automated medication dispensing, new equipment, tracking systems)
	Simulations

In table 1, CIs are shown for hospital relocation and evacuation situations involving IMUs. In table 2, CIs are shown for hospital relocation and evacuation situations involving ICUs. Only the first 20% of the failure modes identified using Pareto’s principle are analysed. CI scores are shown for failure modes before (CI_a) and after (CI_b) applying mitigation measures, together with the percentage reduction (∆). Empty boxes correspond to failure modes affecting only the other situation. Some failure modes were grouped under a 'Global' step heading because they affected every step. Table 3 explains all the mitigation measures in more detail.

Discussion

Criticality analysis and determination of failure modes

An FMECA was performed on the medication processes used by our hospital’s IMU, because it had the largest number of patients, and its ICU, because it had the most critically ill patients. All 59 failure modes found for the hospital relocation situation were also applicable to the evacuation situation. These findings consolidated our hypothesis that these two situations were similar enough to be analysed in a comparable way.^{14 15} Furthermore, the risks related to evacuation were always greater than the equivalent mode of failure for a hospital relocation: the unexpectedness of evacuation situations leads to greater risks than do anticipated planned relocations. This also explains why some failures are specific to this situation and had to be added. However, each subtask’s mean CI score evolved depending on the setting and unit involved (figure 2). The greatest IMU risk was at the departure from the old hospital whereas, for the ICU, it was at the new hospital site. This difference might be because an ICU’s HCPs are well drilled in managing medication during acute situations in a known environment. However, any modification to this environment, such as transportation, increases risks to patients. In contrast, the HCPs caring for patients at the departure hospital’s IMU carry out many interventions, each with their own risks, but patient transportation to a new environment involves fewer safety-related issues because patients are stable. This highlights the importance of performing risk analyses on medication processes for various types of hospital ward because the distribution of risk throughout these processes is specific to the setting.

Safety improvement analysis

With FMECA and specifically the determination of CIs, the impact of the measures can theoretically be estimated. Implementing mitigation measures on medication processes for hospital relocation and evacuation situations lowered all the CI scores. Improvement analyses also showed that most mitigation measures could be used for both situations, with rare mitigation measures being specific to evacuation due to its inherent unpredictability. However, the effects of mitigation measures were lower for evacuation because its impacts are difficult to anticipate and fully plan for. Indeed, the overall estimated impacts of mitigation measures for both units were greater for hospital relocations than for evacuations. The following sections describe the mitigation measures for medication processes that were recommended to our hospital management before the institution’s relocation (figure 1).

Checklists

Using checklists was the most significant mitigation measure, affecting half of the failure modes. Checklists gather information on the pre-departure medical examination, medication handling, transfer itself, continuous health monitoring and location tracking of patients throughout the move day. Comeau et al developed three move-day checklists. They also performed multiple simulations before their hospital relocation, followed by specific debriefings to refine processes.⁹ Using a checklist has been shown to improve patient safety during transport²⁸ and for disaster preparedness.^{29 30} Comeau et al examined 2506 patient transports using checklists and 97.6% reported no complications.²⁸ Performing an FMECA to build a checklist for the present study enabled specific adaptations to be made to medication processes with regard to the hospital departure and arrival settings. For example, a checklist is specific to a patient and must stay with them to facilitate monitoring, tracking and transmission. The checklist was used by physicians, nurses and the transport team. It also contains precise instructions, such as the need to replace pumps with syringe pumps before transport (vehicle vibrations can disrupt pumps) or to check oxygen levels and batteries. Special checklist items were created for physicians, such as verifying that changes to the patient’s medication or condition have been reported in their electronic medical records. Although each checklist can be customised to the patient’s medical specialty setting, it is essential that this is done based on an initial single comprehensive hospital checklist in order to avoid the difficulties related to multiple checklists.

Medication handling protocol

Safe medication handling is essential, but it is implemented differently in IMUs and ICUs, including during hospital relocations or evacuations. Indeed, separating IMU patients from their medication was noted as a risk mitigation measure during transportation for hospital relocations. Medication should preferably be administered before and after transportation and not on the move unless as part of essential continuous treatments. Additionally, patients’ medications are recorded in their electronic medical record and prescriptions can be stopped, administered or postponed until arrival at the new hospital site, thus ensuring electronic traceability. On the other hand, ICU patients may require continuous treatments or the use of life-saving emergency medication.³¹

During a hospital relocation, essential medicines should be prepared before the patient’s departure and should follow the patient during their transfer so as to limit additional risks. In the event of an evacuation, emergency bags should accompany patients to ensure the immediate availability of life-saving drugs. Additionally, an Advanced Medical Post (AMP) can provide an external supply of emergency medicines and can be used to create a safety checkpoint. Likewise, O’Leary et al planned a safety break during the transfer between two units in order to solve any potential health-related issues during the journey, including equipment failure or medication adjustments.³¹

Transmission

A patient transmission protocol and a checklist should be used to reduce the probability of transmission-related adverse events. In particular, the same shift rotations of HCPs should be present at the departure hospital on the day before the move and at the new hospital on arrival, thus increasing the probability of correct transmissions and patient safety.

Technical and human support

Mitigation measures found through the FMECA highlighted the importance of technical and human support. The IMU and ICU in the new hospital would be equipped with an automated medication dispensing system staffed by pharmacy technicians when patients arrive, so the risk of not having access to patients’ treatments is low. For example, pharmacy technicians would check patients’ prescriptions before their departure to ensure that all the drugs they need are present at the new hospital location. Protocols for managing patients’ treatments should be used before, during and after patient moves to ensure continuity of care in drug use in each unit. These should be created for such specific medications as opiates, vital drugs and drugs requiring a cold chain. The same protocol should be followed in the event of an evacuation. Finally, clinical pharmacists should be available at the departing unit to assist HCPs with medication management. Indeed, the literature describes the clinical pharmacist’s essential role in improving patient safety; for example, their presence has reduced the number of medication changes during transitions of care and improved the quality and efficiency of care.^{32 33}

Additional evacuation preparedness

Additional mitigation measures were included in our recommendations to improve preparedness in case of an evacuation, with all its inherent unpredictability. The main improvement was equipping each ward with an evacuation kit containing hospital floor plans, horizontal and vertical evacuation plans, the departure checklist, an algorithm for patient triage and evacuation, procedures for working with degraded resources and a pen. Also, an emergency bag containing vital drugs and, if necessary, some antidotes ensures short-term drug supply before other support can be established. In particular, cooperation with an AMP ensures access to drugs if they are no longer available at the departure hospital.

Overarching mitigation measures

Training and practice exercises are crucial overarching mitigation measures because they can affect the entire process of relocation or evacuation. Indeed, a hospital with staff who have been well trained in a given situation has a lower probability of hazardous events occurring.^{8 12} Similarly, increasing staff numbers before the event is also known to positively affect its outcome.^{4 5 16}

Finally, it is worth noting that a recent similar study highlighted the relevance of using such an FMECA-type evaluation to anticipate the impact of our central hospital pharmacy relocation.³⁴

Study limitations

Most of the present study’s limitations were related to time constraints and the use of an FMECA. Time constraints only allowed us to analyse the medication processes in two units, even though neonatology is also a high-risk ward, for example. Also, medication processes are interconnected with many other processes (eg, dealing with patients’ families, internal transport including elevators, meal management) which also deserved analysis. Regarding the FMECA itself, it is a subjective method dependent on the number of team members participating and its interdisciplinary nature. FMECA also aims to be an iterative methodology—applying mitigation measures and then carrying out a new round of analysis—but this was not the case in the present study because only one hospital relocation had to be done. For the same reason, the post-mitigation measure CI scores are currently only theoretical and are based on the perceptions of the FMECA analysis group’s participants. However, the success of the actual relocation shows that performing this risk analysis was certainly beneficial for the safety of the operation.

Conclusion

A well-known, simple, efficient methodology was used to evaluate the risks of hospital relocation or evacuation on medication processes and patient safety. Findings suggest that implementing the mitigation measures recommended by this approach would significantly reduce risks. The present study demonstrated the usefulness of risk analysis methods for improving preparedness and patient safety in any planned relocation or unplanned evacuation process, such as during a natural disaster or an epidemic. In the future, relocation simulations to test tools and mitigation measures should be considered, as should after-action reviews of any planned move.

Key messages.

What is already known on this subject

• An FMECA is a risk analysis tool used to identify potential failures in complex processes and their effects, thus enabling a reduction in associated risks through mitigation measures.

• Hospital relocations are complex events requiring specific risk management approaches, but there are no reports in the literature describing medication processes in the context of a relocation.

What this study adds

• Using an FMECA-type instrument before a hospital relocation enabled us to anticipate some of the risks related to medication processes, thus improving preparedness and, ultimately, patient safety.

• Such methods and results can help to improve the quality of healthcare practices in diverse and changing environments, such as when a hospital must relocate or evacuate or prepare for this type of event.

Data availability statement

Raw data are available upon reasonable request.

Ethics statements

Patient consent for publication

Not required.