9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

PostHeart
TexasTechUniversityHealthSciencesCenter
Hutto,Texas,UnitedStates
HospitalOther

Aim:ReduceRPNforpostopenheartpatientsbyeliminatingdelaysinelectrolytereplacementby25%in6months.
ProcessData
Date:11/25/2014
Step

Description

RecieveptfromORanddrawstatlabs

FailureMode

Causes

Effects

Notimmediatelydone
becauseofhemodynamic
instabilityofpt.

Instabilityofpt

Delayinelectrolyte
replacement

Step

Description

Laboratoryreceivesbloodandbeginsprocessing

18 Havemultipleteam
membersinplaceto
accomplishalltasksquickly

FailureMode

Causes

Delayinprocessingstat
bloodwork

pneumatictubesystemdown delayinprocessinglab
results

12 Ensureappropriatestaffing

Delayinprocessingof
bloodwork

Inadequatestaffing

24 Ensureadequatestaffing

Step

Description

Laboratorypostsresultsofbloodwork

Effects

Occ Det Sev RPN Actions

Delayinnursenotificationof
abnormalvalues

Occ Det Sev RPN Actions

FailureMode

Causes

Effects

Delayinpostinglabresults

Inadequatestaffing

Delayinnursingrecognition
ofneedforreplacement

36 ensureadequatestaffing

Delayinpostingresults

Multiplesamplesrunning

Delayinnursenotificationof
abnormalvalues

12 Havededicatedmachinesfor
postheartptswhentheyare
scheduled.

Step

Description

Nursereviewslabresults

FailureMode

Causes

Nursedelayedinreviewing
postedlabresults

Nurseunabletoreviewlab
Delayinrecognitionofneed
workincomputerbecauseof forelectrolytereplacement
patientfriability

Step

Description

Nursenotifiespharmacyofneededreplacement

Effects

FailureMode

Causes

Effects

Delayinprocessingoforder
perprotocol

Inadequatestaffingof
pharmacy

Delayinptreceptionof
replacement.

Step

Description

Pharmacyprepareselectrolytereplacement

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

4

72 Havelabpersonnelcontact
nurseviaphonewithany
abnormalvaluesforpost
heartpts.

Occ Det Sev RPN Actions

2

12 Ensureadequatestaffingor
havededicatedpharmacist
foropenheartproceduresas
needed.

FailureMode

Causes

Effects

Delayinpreparationof
electrolytereplacement

Inadequatepharmacy
staffing.
I

Delayinnursereceiving
medication

12 Ensureadequatestaffing.
Ensureadequateelectrolytes
onhand,andmake
contingenciesbeforehandif
necessary.

Delayinpreparationof
electrolytereplacements

Inadequateingredientsfor
medication

Delayinptreceptionof
replacement.

12 Ensureadequateingredients

Step

Description

Nurseretrieveselectrolytereplacementfromtubesystem

FailureMode

Causes

Delayinretrieving
medications

Ptinstabilityrequiresnursing Delayinptreceiving
presence
medication.

Step

Description

Ptreceiveselectrolytereplacement

Effects

FailureMode

Causes

Effects

Delayinptreceiving

LackofIVequipment

Delayinelectrolyte

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

3

54 Haveadequateancillarystaff
onhand.

Occ Det Sev RPN Actions

1

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=18798&ScenarioId=20819&Type=1

6 Ensureadequateequipment

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

medication

replacement.

onhandpriortoreceivingpt.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

270

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=18798&ScenarioId=20819&Type=1

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