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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
FailureModesandEffectsAnalysis(FMEA)Tool
2015MedSurgFallsFMEASSRMC
ShandsStarke
Starke,Florida,UnitedStates
HospitalCommunity
Aim:Reducetherateoffallprevalenceby50%.(Fallsperpatientday)
ProcessData
Date:03/11/2015
Step
Description
FallRiskassessment
FailureMode
Causes
Inaccuratefallrisk
assessmentleadsto
unidentifiedrisk
Inconsistenteducationto
Patientathigherriskgoes
staffmembersregardinguse unidentified
offallrisktool
Effects
Nursedoesnotgiveayellow
armband
Step
Description
NoimplementationofYellowSocks
FailureMode
Causes
Effects
Slip/trip/fall
Lackofprecautionsinplace,
noinjurytosevere
Step
Description
Technology/alarmfailures
FailureMode
Causes
Effects
Alarmsnonfunctional,not
setornotavailable
Inattention,lackofresets
followingcare,patient
tampering,devicefailure
Highriskpatientsmayhave
unintendedOOBactivity
possiblyresultinginfall,no
staffawarenessofactivity
duetodependenceonnon
functioningalarmtoalert.
AlarmnotsettoCentral
monitoring
Step
Description
FailuretoreportviaSBAR
FailureMode
Causes
Effects
Fallrisknotcommunicated
140
10
150
Description
MedicationInfluencesonFallRisk
140
140 Incorporatealarmtestinto
regularrounding,review
alarmparametersand
functionaspartofroutine
patientevaluations
200 Allbedalarmswillbesetto
"CentralMonitoring"forfall
riskpatients.
Step
108
FailureMode
Causes
Effects
Overmedicationeffectswith
newmedicationsor
unfamiliarmedicationsorin
combination
Acuteillness,paincontrol,
physiologiceffectsand
interactionswithnew
regimen
Progressivesymptomsduring
thecopurseofstayresulting
intemporaryincreaseinfall
likelihood
60
Dizziness,ataxiafalls
32
Slowedorimpaired
intreractions,timingand
judgementsiorreactionsdue combiningofmedications
tomedicationsandtimingof
administration
Step
Description
EnvironmentalConcerns
FailureMode
Causes
Effects
Bedsideclutter
Lackofcontrolofpersonal
items
Slip,tripfall
15 Vigilanceinmaintaining
order,encouragepatientsto
sendnonessentialshome
Careitemsonwheels,IV
poles,bedsidetables,
tubings,electricalcordsetc
Neccessarycareitems,
subjecttohaphazard
placement
Slip,trips,falls
15
Unfamiliarenvironment
particularlyatnight
Elderlyconfusion,low
lighting,needforbathroom
use
wandering,slips,tripsfalls
40
CalculatedTotals
TotalRiskPriorityNumberfortheprocess
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19387&ScenarioId=21348&Type=1
1040
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9/14/2015
InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
Occ: LikelihoodofOccurrence(110)
Det: LikelihoodofDetection(110)
NOTE: 1=VerylikelyitWILLbedetected
10=VerylikelyitWILLNOTbedetected
Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)
Annotation
None
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19387&ScenarioId=21348&Type=1
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