9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

REHABCODEBLUE
BluegrassCommunityHospital
Versailles,Kentucky,UnitedStates
HospitalCommunity

Aim:ReduceRPNforPatientDeteriationinOutpatientREHABTherapyDepartment
ProcessData
Date:10/10/2007
Step

Description

Identificationthatpatienthasaproblem

FailureMode

Causes

Effects

Delayinidentificationthat
thereisadeclineinstatus

NobaselineO2satorVS
obtained

Delayintreatment

FailureMode

Causes

Effects

Delayinstoppingtreatment
basedonphysical
appearanceandpatient
complaintonly

Patientstreatementoftenis
exertionalandpatientsare
oftennotingoodphysical
conditioniewillc/obeing
tire,SOBandperspiring

Delayinassessmentand
treatment

FailureMode

Causes

Effects

Differencesinassessment
findingsbetweentheapist

Lowvolume,highrisk
situationinnewfacility.
Noconsistentassessment
toolfordocumentationof
assessmentinthissitation

Delayintreatment

Step

Description

Stoptreatment

Step

Description

Assessthepatient

Step

Description

a.Treatableissueabletocont

Step

Description

a.1Givejuice,restresumetreatment

Step

Description

b.Improvedwithrest,notabletocontinue

FailureMode

Causes

Inconsistencyinwhattodoin Lackofstandardprocedure
eachsituation
innewlocation
Step

Description

b.1AdvisedtofuwithPCPimmediately

Effects
Inconsistentpractice

FailureMode

Causes

Effects

Patientdeclineafterleaving
department

Unexpectedchangein
conditionbasedon
inconsistentassessment
findings
PCPnotavailable
Nofollowupafterward

Untowardpatientoutcome

Step

Description

b.2Patientcontinuestodeclinelosecons.

FailureMode

Causes

Effects

Noprocedureinplace

Newdepartmentoutof
physicalhospitalbuilding

Potentiallackofequipment
andprocedure

Occ Det Sev RPN Actions

4

32 InvestigateobtainingO2Sat
monitorandDatascopefor
routinebaselineassessment
onmodtohighriskpatients
Updatebasicassessment
toolsobtained

Occ Det Sev RPN Actions

4

32 Improveonstep1of
baselineassessment
notes:Clarificationand
educationprovided

Occ Det Sev RPN Actions

3

45 InvolvestaffinFMEA
processbefore
policy/proceduredevopment
*statffeducationandpolicy
clarificationwithspecific
informationonpttype

Occ Det Sev RPN Actions

9

324 DevelopP&Pwithmulti
departmentinvolvement

Occ Det Sev RPN Actions

8

512

Occ Det Sev RPN Actions

8

10

80 RobtocontactGtownwho
hasasimiliarphysicalsetup
forcomparison

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1025

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

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=5108&ScenarioId=6054&Type=1

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

10=VerylikelyitWILLNOTbedetected

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

Annotation
None

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=5108&ScenarioId=6054&Type=1

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