9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

4thfloor,Chestpain
UnitedStates
HospitalCommunity

Aim:ImprovetransfertimeforSTEMIpatientsonthe4thfloor.
ProcessData
Date:03/26/2015
Step

Description

RecognizesignsandsymptomsofAMI

FailureMode

Causes

Patientdoesn'tverbalize

1.DecreasedLOC
2.Doesn'twanttobotherthe
nurse
3.Calledbeforewithno
response
4.Ptdoesn'tknow

10

10

500

Symptomsarenotclassic

1.Lackofknowledge
2.Female
3.Diabetic

10

10

800

Patientlabeledadrugseeker 1.multiplepainadmits
2.hxofdrugabuse

10

10

500

Nursedoesn'trecognize
symptoms

1.lackofknowledge
2.Oddsymptoms

10

200

Nurseblowsitoff

1.lackofknowledge
2.Understaffed
3.Numerouspriorcomplaints

10

10

300

Step

Description

AssessmentbyRNincludingvitalsigns

Effects

FailureMode

Causes

Nursedoesnotdoone

1.Understaffed
2.Multiplesickpatients

81

Delay

1.Offfloorwithanother
patient
2.Communicationthinking
someoneelsewashandling.

243

Faultyequipment

1.Dynamapbroken
2.Biomedoutofdate

162

Lackofequipment

1.Missingdynamap

162

Assessmentiswithinnormal
limits

1.silentMI
2.Symptomsnotbadenough
yet

210

Telemetry

1.Noonemonitoring
2.ICUbusierduringdayshift

147

Step

Description

Callthephysician

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Can'tgetintouch

1.noanswer
2.asleep

10

10

700

doesn'tcallback

didn'tgetthemessage

10

10

800

callservice

1.lackof
2.theydon'tknowwhoison
call

10

10

700

Delay

1.goingthroughofficeto
speakwithMD
2.Onhold
3.Numerousprompts

10

10

900

"I'mnotoncall"

1.Outoftimeframe
2.Didn'tknowhe/shewason
call

10

10

500

Readingcallschedule

ChangesQ15m

360

Fearofcalling

newnurse
MDhasyelledbefore

128

MDisontheway

PreviousknowledgethatMD
willbeheresoon

128

Inconsistantwaystoreach
MD

EachMDdoesitdifferently

10

720

Step

Effects

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

Description

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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
OrderanEKG

FailureMode

Causes

RTnotcalledforstatEKG

1.Didn'tknowtocall
2.Didn'tknownumber
3.Operatordidn'tanswer
4.Beepermalfunction

10

90

Orderdoesn'tprint

1.Printerbroken
2.Outofpaper
3.Jammed

192

Nooneisavailabletosee
printedorder

1.Staffoutofdepartment

10

360

Didn'tgetanorder

1.MDdidn'torder
2.MDhasn'tcalledback

10

480

Orderedincorrectly

1.Multiplewaystoorder
2.Orderedonwrongpatient
3.Notstat

108

Step

Description

Orderstatcardiacenzymes

Effects

FailureMode

Causes

Nursedidn'tcallLab

Nursedidn'tknowtocallfor
statlabdraws

90

Orderdoesn'tprinttolab

Printerbroken,outofpaper,
orjammed

120

Nooneavailabletosee
printedorder

Staffoutofdepartment

432

Didn'tgetanorder

MDdidn'torder
Haven'tspokenwithMD

288

Orderedincorrectly

Multiplewaystoorder,
orderedonwrongpatient,
notorderedstat.

108

Step

Description

EstablishIVaccess

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Didn'tgetanorderfromthe
MD

Haven'tspokenwithMDyet

PoorAccess

Dialysis
Steroiduse
Obese
Bloodthinners
IVdruguser

10

10

400

Delay

Inexperiencednurse
Lowsupplycartstock

72

Step

Description

Drawcardiacenzymes

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Delay

Didnotreceiveorder
Didnotreceivecall
Withanotherpatient

324

Difficultstick

Pooraccess

96

Step

Description

AdministerNTGslx3doses

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Noorder

Haven'tspokentoMD

10

630

VSoutoflimit

BPlow

120

Delay

Notinpyxis
NotineMAR

324

Step

Description

RT@bedsideforEKG

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Delay

Noorder
NoCall
Withanotherpatient

10

10

500

EquipmentFailure

malfunction

10

10

100

Step

Description

10

Placeonoxygenifneeded

Effects

Occ Det Sev RPN Actions

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Noorder

MDdidnotorder
MDhasn'tcallback

10

640

O2satWNL

Symptomsnotaffecting
breathingpatternorO2sat

10

560

Step

Description

11

Oncallphysicianwillcometothehospital,readtheEKG,and

Occ Det Sev RPN Actions

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
evaluatethepatient

FailureMode

Causes

Hedoesn'tcome

Refusestocome
Hasn'tcalledback
Says"notoncall"

Effects

10

10

10 1000

Delay

Notinthehospital
farcommute
seeingotherpatients
nosenseofurgency

10

10

10 1000

Step

Description

12

IfitisaSTEMI,thenMDwillpeertopeertransfertoECM
Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Doccan'tgetintouchwith
ECMdoc

Busy
nights
weekends

10

80

Docdoesn'tseeSTEMI

lackofknowledge

10

60

Delay

Unsurewhotocall
Unsurewhatnumbertocall
Goingthroughmultiple
peopletogetconnectedto
thecorrectperson

10

60

Step

Description

13

IfitisaNSTEMI,thenwaitforcardiacenzymestoresult

FailureMode

Causes

Delay

Longprocessingtime
Needrecollect

Step

Description

14

CallEZtransfer

Effects

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

9

486

FailureMode

Causes

Delay

Don'tknowthenumber

10

180

EZcan'tgetintouchwith
ECM

Busy
Notansweringphone
Don'tknowwhotocall

36

EZcan'tgetroom
assignment

ECMfull

12

Step

Description

15

AdministerAspirin

Effects

FailureMode

Causes

Docdidn'torder

lackofknowledge
Haven'tspokentodoc

288

Delay

Notinpyxis
NotineMAR

40

Notgiven

busywithtx
allergy
forgot
ptwithn/v

72

Step

Description

16

FaxfacesheettoEZtransfer

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Delay

doesn'tknowthenumber
Doesn'tknowhowtousethe
faxmachine

12

Doesn'tfaxthefacesheet

Fazmachinemalfunction
Notime
doesn'tknowtheyneedto
faxthefacesheet

12

Step

Description

17

Callforanambulance

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Multiplephonecalls

Callingdifferentservices

10

540

Delay

Don'tknowthenumber
Slowresponsetime

10

540

Nursedoesn'tcommunicate
emergency

lackofknowledge
Poorcommunication

10

120

Step

Description

18

Preparedocumentation

FailureMode

Causes

Delay

Unsurewhattosend
Busywithpatient
Copiermalfunction
Dependsonthefacility
Burndiscs

Step

Effects

Occ Det Sev RPN Actions

Effects

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

2

16

Description

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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
Documentonhospitaltohospitalintervention

FailureMode

Causes

Notdone

Nursedoesn'tknow
Meditechdown

Effects

Occ Det Sev RPN Actions

3

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

18839

Occ: LikelihoodofOccurrence(110)
Det: LikelihoodofDetection(110)
NOTE: 1=VerylikelyitWILLbedetected

10=VerylikelyitWILLNOTbedetected

Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)

Annotation
Change:10593

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