9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

RRTsatNHS
NorthwestMedicalCenter
Springdale,Arkansas,UnitedStates
HospitalTeaching

Aim:IncreasestaffawarenessofwhentocallRRTandpreventCodeBlue'soutsideofIntensiveCare
ProcessData
Date:04/22/2010
Step

Description

Staffrecognizessymptomstoreport

FailureMode

Causes

Effects

Occ Det Sev RPN Actions

Staffnoteducatedon
procedure

72 Continueeducationtoall
staffnurses
Cardsgiventoallstaff
nurseswithindicatorslisted
Orientation&cardsgivento
allnewemployees
MonitorunplannedICU
transfersandoutofICU
codesmontlytotrack

staffcalls"0"insteadofusing Newstaffmaynotknowhow Delaywhenoperatornot

551
topagefromphonesystem
availableafterhours

12

Currentwayofdoingvital
signs/assessmentsdon't
supporttimelyinterventions

Step

Description

NurseconsultsChargeNurse/TeamLeader/AdminSupervisorbefore
RRT

Step

Description

Attendingcaregivernotifiesoperatortopageteam

FailureMode

Causes

Effects

Teamforgetstocallinto
notifyoperatorwhoistobe
called

Step

Description

Teamnotified
Causes

Overheadpagingnotheard
byalliedhealthstaff.

Ifstaffinareaswhere
Delayedresponsetopatient
overheadpagingisnotclear. room.

Effects

2callswithinabriefamount
oftime

Step

Description

Physiciannotification

FailureMode

Occ Det Sev RPN Actions

3

FailureMode

Causes

Effects

120 MonitoroutofICUcodesand
unplannedtransfers

10

60 OperatortocallICU,ERor
311/117supervisorifno
onecallsinforashifttofind
outwhoresponderis

Occ Det Sev RPN Actions

2

108 Educatestafftousepagersif
neededtocommunicatewith
RRT

10

100 Operatortotransfercallto
RRTRNandthatRNwill
triage

Occ Det Sev RPN Actions

Teamforgetstonotify
physician

10

10

100 Teameducatedtonotify
physicianonallcalls

Physiciansveryconcerned
abouttimely
notificaiton/Physiciandoesn't
returncallswithfirstbeep

10

10

300 Areaaddedto
documentationformfor
beeped/timereturncall
Willtrackwithmonthlydata
attendingphysician,called
physicianandresponse
timestopresenttophysician
groups

Step

Description

Teamrespondstofloor

FailureMode

Causes

Effects

Equipmentneedednot
complete

Inexperienceofunitto
prepareforteamresponse

delayininterventions

Occ Det Sev RPN Actions

2

10

40 Staffeducatedtohave
equipmentavailableforRRT

BPcuffmissingfromkit

10

30 ALLBPcuffswillbelabeled
RRTbySPD
IFbincomesbacktoSPD
withoutBPcuffinitSPDto
notifyteam

Documentationformsmissing

10

30 CNSgroupwillcheck

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=10387&ScenarioId=12167&Type=2

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
clipboardsmonthlytomake
sureadequate
documentationformsin
them

RRTtoobusy/forgetsto
replacesuppliesused

Step

Description

RRTtakesaction

Teaminexperience,obstacles Insufficientsuppliesinthe
togettingsuppliesafter
eventofanotherRRTin
hours
sameshift

10

80 Havebackupsupplies
availableafterhoursandon
weekends

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1052

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=10387&ScenarioId=12167&Type=2

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