9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

Wound&SkinDecubitus
Camp.Co.Mem.Hosp.
Gillette,Wyoming,UnitedStates
HospitalCommunity

Aim:Reducetheincidenceofdecubitithroughoutthehospital
ProcessData
Date:12/12/2003
Step

Description

Reducedecuitus

FailureMode

Causes

Lackofrepositioninginbed
orchairs

Nursefeelliketoobusy
Decuitusisformed
Notmadeapriorityincare
Pt.notabletotolerateturnin
inbed

Effects

Occ Det Sev RPN Actions

5

150 Priorityinplanofcare
Educationofstaffon
importance
Decreaseuseofrotating
beds

Lackofassessment
Flowsheetdoesnottrigger
useofprotocol
Incompletecharting

Nursenotfamiliarwith
protocolsforpreventionand
care
RN'snotclearonhowto
chart
Rushedincharting
NotreportedtoRN

120 WorkwithISandnursingto
clarifyuseofBradenScale
maybesetitlowerthan14
Chartingwhichwilltrigger
useofprotocolandplaceto
chartwhichoneisused.

Properlabsarenotbeing
Physicianrefusetofollowthe Difficulttotracknutritional
donewithpt'sreceiving
protocol
status
enteralfeedingorTPN
PreAlbumins<18needtobe
doneweekly

25 Encouragephysicianstouse
theprotocolsforEnteral
FeedingandTPN
Orderprealbuminsper
protocol

Nutritionisnotstartedin
timelymanner
Difficultyingettingenough
proteininpt'swithpropofol
running

Physiciansdon'torder
Pharmacyhastospecialmix
toaddproteintoTPN

Poornutritionstatus
Woundsdon'theal

80 Encouragephysicianstouse
enteralfeedingsorPPNifpt.
isatrisk.
Useofprotocolswhen
Bradenassessmentshows
risk

Specialtybednotorderedin
timelymanner

Protocolsnotused
Physiciansneedtobe
remindedofneed

Decubitusformedor
worsenedifalreadypresent

192 UseW&Sprotocols
Educatestaffwhichbedsare
appropriate

PTnotstartedintimely
manner

Protocolsnotusedaccording
toassessment
RN'sdon'tremindphysicians
ofneed

Woundcaremaynotbedone
ROMandactivitiesmaybe
limited

80 Educationofstaffonusing
protocols.
Encouragephysicianstouse
protocols

Barrierproductsnotroutinely
usedwithincontinence
Incontinencecarenotgiven
intimelymanner

Nursesbusy
Noteducatedinuseof
barrierproductstoprotect
skin

Breakdownofperineal/rectal
area

120 Educationofstaffinhowskin
breaksdownwith
incontinence
Educateinbarrierproducts
available

Lackofeducationforstaff

Everyonesbusy
Newemployees
Personnelnotcomfortablein
teaching

Staffdoesnotknowhowto
takecareofwoundsor
preventthem

125 Makeshorteducationtimes
forstaff
Keypeopleonfloorstohelp
witheducation
Retentionofstaff
Useofwoundboxes

Diabetesnotincontrol

Poorptcompliance
Bloodsugarsinhospitalare
oftenhighthewhole
admission

Woundhealingdelayed
Skinbreaksdown

135 InvolveDiabetesCenter
Workwithphysiciansto
decreaseBS
Involvehomehealthupon
discharge

Notreatmentdocumented

PossiblynoPTconsult
Lackofknowledgeofwhat
treatmenttodo

Delayinhealing

80 Educationofstaffinwound
care
EarlyinvolvementofPT

Lackofuseofsupportive
products

Don'tuseproductsavailable Heelsbreakdown,footdrop
Mayhavenotbeenused
mayoccur,decubitusmay
priortoadmission
develop

144 Useproductssuchasheel
protectors,headfoam
protectors,pillows,footdrop
protectors,etcareavailable.
Educatefamilyonskincare,
involvehomehealth
Coordinatedischargecare
withnursinghomeifapplic.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1251

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

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=213&ScenarioId=193&Type=1

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9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

10=VerylikelyitWILLNOTbedetected

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

Annotation
Change:Goalistoreduceby50%byEducationofstaff

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=213&ScenarioId=193&Type=1

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