Using Failure Mode and Effects Analysis (FMEA) Methods to Identify Barriers Contributing to Low
Human Papillomavirus (HPV) Vaccination Rates in a University-Based Community Health Clinic
Kelsey Palmer, PharmD1; Nancy Nickman, RPh, PhD1,2; Krystal Moorman, PharmD, BCPS1,3; David Owen, MD3;
Diana Brixner, RPh, PhD1,2; Brandon T. Jennings, PharmD, BCACP1,3
,
1
University of Utah College of Pharmacy, Salt Lake City, Utah; 2University of Utah Pharmacotherapy Outcomes Research Center, Salt Lake City, Utah;
3
University of Utah Hospitals and Clinics, Salt Lake City, Utah
Vaccine Process Steps
Introduction / Background
•  Approximately 79 million individuals in the US are infected with HPV, with 14
million becoming newly infected each year1
•  Utah has the lowest rate of immunization in the US2
•  HPV remains one of the most underused vaccines3,4
•  Likely due to parental beliefs that HPV is not severe or a discomfort
discussing the sexual implications of the vaccine3
•  Significantly more parents note safety concerns with the HPV vaccination
than with other childhood vaccinations 4
Pre-visit planning (PVP):
•  Immunizations reviewed and pended for well child check in pediatrics, note
made in chart
•  Immunizations reviewed and pended for well child check in family medicine
•  No Epic alerts for vaccinations in internal medicine (IM)
Rooming the patient (RN or MA):
•  Patient asked about immunizations when roomed in pediatrics (always for
well child check, sometimes for sick visits)
•  Patient asked about immunizations when roomed for well child check in
family medicine
Objectives
•  Conduct an FMEA to identify failure modes that contribute to adolescents not
being vaccinated against HPV in a university-based community health clinic
•  Design and implement a future intervention based on this quality improvement
initiative’s results
Provider sees patient:
•  Parent agrees to vaccination
•  Provider signs orders
•  After visit summary sometimes provided to patient
Methods / Process
• 
• 
• 
• 
• 
Assemble a multidisciplinary team who provide care for adolescent patients
Map all steps in the HPV vaccination process
Identify potential failure modes at each step identified
Utilize FMEA methods to assign a Risk Priority Number (RPN) to each failure
Assign RPN scores based on likelihood of occurrence, likelihood of
detection, and ability to correct locally
•  Failure mode(s) with highest RPN score(s) to be targeted for potential
process improvement
Vaccine given
2. 
Correspondence
Please address inquiries to: Kelsey Palmer, PharmD, Community Practice Resident
University of Utah College of Pharmacy/Bowman’s Pharmacy
[email protected]
All authors have no relevant conflicts of interest to declare
Presented at: APhA Annual Meeting and Exposition; March 27-30, 2015 San Diego, CA
3. 
4. 
Top Failure Modes
Likelihood of Likelihood
Occurrence of Detection
Ability to
correct
locally
RPN
Follow-up not scheduled
10
8
10
800
After visit summary not
provided to patient
10
8
1092.08%
800
Immunizations not
addressed in PVP for IM
9
9
9
729
Immunizations not
checked when patient is
roomed in IM
9
9
9
729
HPV vaccination not
discussed in sick visits
9
9
9
729
Patient is not informed
when back in stock
10
8
9
720
Conclusions
References
1. 
Results
Human Papillomavirus (HPV). Centers for Disease Control and Prevention website. http://www.cdc.gov/hpv/vaccine.html. Updated
February 5, 2013. Accessed August 15, 2014.
Elam-Evans LD, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents
aged 13-17 years- United States, 2013. Atlanta (GA): Centers for Disease Control and Prevention. 2014 July 25. MMWR 63(29);625-633.
McRee AL, Gilkey MB, Dempsey AF. HPV Vaccine Hesitancy: Findings From a Statewide Survey of Health Care Providers. J Pediatr
Health Care. 2014 July 10.
Jacobson RM, Roberts JR, Darden PM. Parents’ Perceptions of the HPV Vaccine: A Key Target for Improving Immunization Rates. Expert
Rev Clin Immunol. 2013, 9(9):791-793.
•  Failure modes with highest RPNs are related to incomplete vaccine series
•  Vaccinations are not frequently addressed in Internal Medicine
•  Opportunity often missed to discuss vaccinations when pediatric patients
present for sick or same-day visits
Limitations
•  Data limited to one community practice site
•  Practice setting in academic health center could limit generalizability
•  No pediatrician participation on FMEA team