9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofTransferofCardiacPatientProcess
Town&CountryHospital
Tampa,Florida,UnitedStates
HospitalCommunity

Aim:Toreducetheriskprioritynumber(RPN)forthetransferprocessby80%in6months.
ProcessData
Date:03/26/2012
Step

Description

PatientcomestoER

FailureMode

Causes

ERPhysicianfailedtoordera
troponinonapatient
presentingwithchest
pressure,shotnessofbreath
andahistoryofAfib

PatientwaitedinERtobe
Delayintransferofpatient
admitted.Wasnottreatedfor
cardiacissue.TheERnursing
staffdidnotverifythatthe
troponinswereordered

Step

Description

AdmittingPhysiciancallsfortroponinresults

Effects

FailureMode

Causes

Effects

TheAdmittingPhysician
calledtheERforthresultsof
thetroponin.

TheERnursetoldthe
physicianthattheresultwas
normal.TheERnurse
thoughtthatthelabwould
havecalledifthetestwas
abnormal,butthelabdidn't
callbecausethetestwas
neverordered.

ThepatientremainedinthER
onanICUhold.Thepatient
didnotreceiveanytreatment
forcardiacissues.

Step

Description

AdmittingPhysicianordersatroponin

FailureMode

Causes

Effects

TheAdmittingPhysician
orderedastattroponin

Thetroponinwasnotordered
bytheERnurseortheICU
nursethatwascaringforthe
patientintheER.

Thepatientcontinuedtobe
anICUholdintheERand
wasnottreatedforcardiac
issues.

Step

Description

CardiologyPhysicianordersatroponin

FailureMode

Causes

Effects

TheCardiologistordereda
troponinstat.

Thetroponinwasnotordered
forthreehours.Thersultwas
abnormal.TheCardiologist
transferredthepatientto
anotherfacilityforahigher
levelofcare.

Therewasadelayinthe
transferofthispatienttoa
higherlevelofcaredueto
thedelayinreceiving
troponinresults.

Occ Det Sev RPN Actions

8

512 TheERMedicalDirector
performedinservicingofall
oftheMedicalStaffofthe
importanceofverifyingthat
theappropriatetestsare
orderedontheappropriate
patients.TheERNursing
Directorperformedanin
serviceforallstaffonthe
importanceo

Occ Det Sev RPN Actions

6

288 TheERNursingDirector
inservicedallERstaffonthe
importanceofverifyingthat
labsareorderedandthat
resulsareverified.Oneof
thecomputersintheERhad
theICUprogramplacedonit
sothattheICUnursethatis
caringforanICUpaientinth

Occ Det Sev RPN Actions

7

210 TheICUnursethatiscaring
forthepatientintheERthat
isanICUholdwillhavethe
responsibilityforallcare
giventothepatient.

Occ Det Sev RPN Actions

5

175 AninservicetoallERand
ICUstaffaboutthe
importanceoforderingand
verifyinglabswas
performed.ARootCause
Analysiswasperformedwith
allinvolvedstaffand
departmentstodiscussthe
issueandtoputaprocessin
placetopreventthisfromre

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1185

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=13669&ScenarioId=15599&Type=1

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