9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

Copy(2)ofVTE2014
HamadMedicalCorporation
Doha,Qatar
HospitalTeaching

Aim:ReducetheRiskPriorityNumber(RPN)fortheVTEbelow60
ProcessData
Date:06/11/2014
Step

Description

Patientisadmittedtowardwithdocumentreceivedfromadmission
office

FailureMode

Causes

Effects

Patientisnotavailable

Patient
DAMA/AMA/absconded

delayintreatmentlackof
treatment

Occ Det Sev RPN Actions

2

28 Educateptuponadmission,
providealternative(follow
ups,medication,advise)
ContactPtviapossible
means

delayoftreatment

30

Casewascanceledby
team/unit
Docarenotavailable

stocknotavaialble
staffnotaware
staffforgottoplaceitinthe
ptfile

Step

Description

Chargenurseensuresupplyofassessmentformsinnursingstation

FailureMode

Causes

Effects

unavailableforms

CNstaffareunsureofforms
needed
Nosupply

Delay/lackintreatment.

Step

Description

AssignedNurseensuretheassessmentorderforminmedicalrecord
file

FailureMode

Causes

Effects

Incorrectpaperworkand
ordersselected

staffNurseareunsureof
paperworkneeded

Delayintreatment.

Step

Description

Assessriskwith8hrsbyphyscian

FailureMode

Causes

Effects

Riskassessmentinaccurate

Noriskassessmenttool
Toollessthanadequate
Stafftrainingandeducation
lessthanadequate
physiciannotavailable
(e.g.,competingpriorities)
Translatornotavailable
Historyfrompatientless
thanadequate
(e.g.,poorhistorian,dement

Wrongtreatmentno
treatmentdelayin
treatmentdevelopment
ofPE/DVT
complicationsof
treatment

Occ Det Sev RPN Actions

2

20 Conductthorougheducation
programforrelatedstaffand
establishsypplysystemwith
supplyoffice

Occ Det Sev RPN Actions

6

96 Conductthorougheducation
programforrelatedstaff

Occ Det Sev RPN Actions

4

64 Developstandardized
protocolforVTErisk
assessmentbytypeof
patient
Delineateresponsibilityfor
completingVTErisk
assessment
Establishtimeframefor
completionofVTErisk
assessment
IncorporateVTErisk
assessmentcompletionin
chang

assessmentisdelayedmore
than24hrs

Noriskassessmenttool
Stafftrainingandeducation
lessthanadequate
physiciannotavailable
(e.g.,competingpriorities)
Translatornotavailable
Historyfrompatientless
thanadequate
(e.g.,poorhistorian,dement

notreatmentdelayin
treatmentdevelopmentof
PE/DVT
complications.

72

Assessmentisnotdone

Noriskassessmenttool
Stafftrainingandeducation
lessthanadequate
physiciannotavailable
(e.g.,competingpriorities)
Translatornotavailable
patientDAMA\AMA

notreatmentdelayin
treatmentdevelopment
ofPE/DVTcomplications,
dissatisfaction

48

Step

Description

physcianselecttheapproporiateaction:pharmaceutical/mechanical

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prophylaxis/educateorambulate

FailureMode

Causes

Effects

selectionofinapproperiate
action

Responsibilitynotclearly
delineated
Stafftrainingandeducation
lessthanadequate
Translatornotavailable
Patientscommunication
barriersnotidentifiedor
addressed
noclearprotocol

Incorrect/inappropriate
treatment
notreatmentdevelopment
ofPE/DVT
complicationsoftreatment

168

inapproperiate
medication/mechanical
selected

Nostandardofcare
Doesnotfollowprotocol
Busy
Forgot
Otherpriorities
Didnotcheckassessment
Otheremergentissues

Therapyfailureno
treatmentwrong
treatmentadverseevent
delayinpropertreatment
duplicationof
workreadmission
developmentofVTE
complication.

105 Provideeducationon
protocol
Developorderset

Education/ambulation
selectionisincorrect/not
done

Responsibilitynotclearly
delineated
Stafftrainingandeducation
lessthanadequate
Translatornotavailable
Patientscommunication
barriersnotidentifiedor
addressed
Educationaltoolslessthan
adequate
Noeducationaltools
Patientnotavailab

Incorrect/inappropriate
treatment
notreatmenttherapy
failuredevelopmentof
PE/DVT
complicationsoftreatment
readmission

192

Delayinorder

Toomanypriorities
Assessmentnotavailable
Othermedicalissues
Overlooked

Notreatmentwrong
treatmentadverseevent
delayinpropertreatment
readmissiondevelopment
ofVTEcomplications

Step

Description

Physiciancompleteorder.signandstamp

FailureMode

Causes

Effects

signandstampofordernot
done/delayed

Doesnotfollowprotocol
Labsnotavailable
Physicianinarush
Assessmentnotchecked
Poordocumentation

Notreatmentwrong
treatmentadverseevent
delayinpropertreatment
medicationerror
readmissiondevelopment
ofVTEcomplications

Step

Description

NurseProcesstheordermechanical:administerstockingor
pneumaticcompression

FailureMode

Causes

Effects

Careplannotdone
delayed
inaccurate

Stafftrainingandeducation
lessthanadequate
Responsibilityforcareplan
notclearly
delineated
Handoffcommunication
betweenstaffless
thanadequate
Nursenotavailable(e.g.,
competingpriorities)
Patientscommunication
barriersnot
identi

Otherassessmentscantbe
completed
miscommunicationamong
caregivers
lackofpatienteducation
wrongtreatmentno
treatmentdelayin
treatmentdevelopmentof
PE/DVT
complicationsoftreatment

Step

Description

NurseProcesstheorderambulateandeducate:carryoutinstruction

Occ Det Sev RPN Actions

63 Provideeducationon
protocol
Developorderset

Occ Det Sev RPN Actions

2

28 Provideeducationon
protocol
Developorderset

Occ Det Sev RPN Actions

4

56 Incorporatecareplanin
handoffscommunications
betweencaregivers
Haveseniorleadershipsend
aclearmessagethat
VTEpreventionisan
organizationalgoal
Emphasizeimportanceof
VTEpreventioninstaff
education
Designateunitbasednurse
educa

FailureMode

Causes

Effects

Educationnotdone

Responsibilitynotclearly
delineated
Stafftrainingandeducation
lessthan
adequate
Communicationhandoff
lessthanadequate
Translatornotavailable
Patientscommunication
barriersnot
identifiedoraddressed
Hospitalhasnotidentified

Missedpatient
educationopportunity
patientunabletocomplywith
instructionsimproperfollow
upcare
incorrect/inappropriat
etreatmentnotreatment
therapyfailureDevelopment
ofPE/DVT
complicationsoftreatment

Occ Det Sev RPN Actions

4

60 Identifynurseasprimary
educator
Nursingcommitteeto
identifyresourcesfor
educatingpatientandto
develop
educationforNursesonVTE
risk
assessment,riskreduction
andtreatment

Educationdelayed

Responsibilitynotclearly
delineated
Stafftrainingandeducation
lessthan
adequate
Communicationhandoffless
thanadequate
Translatornotavailable
Patientscommunication
barriersnot
identified

Patientunableto
complywith
instructionsimproper
followupcare
Incorrect/
inappropriate
treatmentno
treatmenttherapy
failuredevelopment
ofPE/DVT
complicationsof

18

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Educationincomplete/
incorrect

Hospitalhasnotidentified
needfor
translati

treatment

Responsibilitynotclearly
delineated
Stafftrainingandeducation
lessthan
adequate
Communicationhandoffless
thanadequate
Translatornotavailable
Patientscommunication
barriersnot
identified
Hospitalhasnotidentified
needfor
translati

Patient
confused/unableto
complyimproper
followupcare
incorrect/inappropriate
treatmentno
treatmenttherapy
failuredevelop
PE/DVT
complicationsof
treatment

Step

Description

NurseProcesstheorderpharmaceutical:photocopysendto
pharmacy

90

FailureMode

Causes

Effects

medicationcopynotsent

lacksknowledgeofprocess
Toobusy
Documentationnotcomplete

Notreatmentwrong
treatmentadverseevent
delayinpropertreatment

1 Provideeducationon
protocol
Developorderset

Therapymaydelay

1 Provideeducationon
protocol
Developorderset
nursecallpharmacyafter30
min

pharmacydidnotrecievethe faxrelatedissues
copy
recievermissedthecopy

Step

Description

10

nurseupdatedocumentation

FailureMode

Causes

Effects

Delayeddocumentation
notupdated

Protocollessthanadequate
Noprotocol
Responsibilityfor
documentationnot
clearlydelineated
Stafftrainingandeducation
lessthan
adequate
Easeofdocumentationless
than
adequate
Currentdocumentationform
doesnot
incorporateDVTrisk

Otherassessmentscant
becompletedormaybe
inaccuratelackof
communicationamong
caregiverswrong/no
treatmentdelayin
treatmentdevelopmentof
PE/DVTcomplicationsof
treatmentunnecessary
rework

Step

Description

11

nursereturnformstopatientfileforaudit

FailureMode

Causes

formsarenotreturnedtofile delayed
forgot
fileismissed

Effects
auditdelayed
physcionsnotesdelayed

Step

Description

12

pharmacydispenseasperpolicyandkeepacopyforaudit

FailureMode

Causes

Effects

medicationisnot
dispensed/delayed

nocopysenttopharmacy
nomedication
ordercancelled
busy

notreatment
developmentofVTE
delayintreatment
complications

Step

Description

13

Nurseadministermedicationasperpolicy

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

3

18 Delineateresponsibilityfor
documentingVTErisk
assessmentinmedical
record
Delineatebackup
responsibility(e.g.,charge
nurse)fordocumentingrisk
assessmentin
medicalrecord.
IncorporateVTErisk
assessmentdocumentation
requirements(includi

Occ Det Sev RPN Actions

1

Occ Det Sev RPN Actions

1

FailureMode

Causes

Effects

medicationisnot
administered

Delayinadministration
forgot
busy
delaydispense
delayofdelivery

Wrongtreatmentno
treatmentdevelopmentof
VTEdelayintreatment
andeducation
complications

Occ Det Sev RPN Actions

2

32

medicationadminstration
delayed

delayedfrompharmacy
nursebusy
forgot

developmentof
VTEdelayintreatment

40 Developprotocolfor
incorporation
ofVTEinterventions,as
appropriate,intreatment
plan
Educatestaff

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1233

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

10=VerylikelyitWILLNOTbedetected

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

Annotation
None

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