EP 49 - COVID-19 Mass Vaccination Patient Flow Proactive Risk Assessment

Background: To mitigate avoidable patient harm, a proactive risk assessment was conducted during the operationalizing of numerous mass vaccination clinics in the midst of a public health emergency. The COVID-19 vaccination rollout met the criteria for a proactive risk assessment as it was a highly complex, novel process. It required a seamless and agile coordination across most departments in the organization and state and local government authorities to achieve a rapid implementation. Through this process the team was able to identify risks and implement actions for all the vaccination sites in real-time.

Methods: A multidisciplinary charter team of 11 disciplines was developed. A Failure Mode Effects Analysis (FMEA) of the COVID-19 mass vaccination process was conducted with immediate action implemented through communication at daily vaccine safety huddles. Patient flow touch point swim lanes were created in order to effectively capture potential risks. Each failure mode was scored using a risk priority number (RPN). Safety incidents were reviewed daily.

Results: Eight mass vaccination sites were opened in rapid succession. 64 unique failure modes were identified and scored. Corrective actions were implemented for identified failures. An 87% improvement from baseline RPN to the post intervention RPN was achieved with only 39 avoidable safety incidents reported.

Conclusions: Through this multidisciplinary approach and leadership commitment, we were able to serve our community overcoming health care disparities by providing safe and equitable administration of 435,295 COVID-19 vaccines within 6 months; reaching capacity greater than 9,000 per day.