9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofSpecimentcollectionandReporting
PremierEndosocpyCenter
naples,Florida,UnitedStates
Other

Aim:Reducethisriskofspecimensandreportsbeinglost
ProcessData
Date:02/11/2010
Step

Description

Specimensareloggedonspecimensheet

FailureMode

Causes

Nurseforgetstolog
specimen

Humanerror,nursehasbusy Delayinprocessingresults
dayforgets

Specimenloggedonincorrect humanerror,distraction
labsheet
Step

Description

NaplesPathsendscouriertopickupspecimens

Effects

Specimengoestowronglab,
specimenlost

FailureMode

Causes

Effects

Courierdoesn'tshow

Caraccident,forgetsthis
stoponroute

Delayinprocessingspecimen

Step

Description

couriersignsforspecimens

FailureMode

Causes

courierforgetstosignand
specimenisleft

Humanerror,rushed,lackof Delayinprocessing
training,distraction
specimen.Iftimesensitive
specimencannotbe
processed

Step

Description

reportsaremailedtofacility

Effects

FailureMode

Causes

Effects

Noreportsmailedinthe
usualtimeframe

Erroratlab,lost

Delayoromissionin
reviewingspecimenreport
andtreatingpatient

Step

Description

receptionistplacesreportonpatientchart

10

Humanerror,lackoftraining, Delayintreatingpatient
distraction

receptionistplaceswrong
reportonpatientchart

distraction,humanerror,
similarpatientnames

10

Description
chartsgiventophysciantoreview

48 Specimenboxtobechecked
attheendoftheday.If
specimensleft,calllab

40 Checkforleftspecimensand
forinitialsofcourieratthe
endoftheday

Occ Det Sev RPN Actions

Causes

100 Nursetoverifylabsheet
whenrecordingspecimen

Occ Det Sev RPN Actions

Receptionistfailstoputthe
reportontheincomplete
chart

Potentialtreatmentofwrong
patientandomissionof
treatmentforcorrectpatient

30 Procedureroomcheckedat
endofdayforspecimens

Occ Det Sev RPN Actions

FailureMode

Step

Effects

Occ Det Sev RPN Actions

64 Reportsloggedinonlab
sheetandcheckeddailyfor
omissions

Occ Det Sev RPN Actions

40 Trainreceptionistanddoa
finalchartauditonall
completedcharts
100 Physicianreviewsthereport
andinitials.Finalchartaudit
oncompletedcharts

FailureMode

Causes

Effects

Physicianfailstoreviewthe
chart

Busyandforgets,human
error

Delayinreviewingreportand
delayintreatingpatient

10

50 Checkthatallreportsare
reviewedbyphysicianprior
toscanningdocuments

chartsgiventowrong
physician

humanerror,distraction

delayintreatmentofpatient,
breachofpatient
confidentiality

10

60 Verifycorrectphysician
roombeforeplacingreports

Step

Description

physicianreviewsreportandsigns

FailureMode

Causes

Effects

physiciandoesn'treviewor
forgetstosign

Busyday,inahurry,
distractions

Delayintreatingpatient

Step

Description

chartsarereturnedtobescanned

FailureMode

Causes

Effects

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

1

10

50 Checkallchartsfor
physician'ssignaturepriorto
placinginthecompleted
chartstobescanned

Occ Det Sev RPN Actions

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=10146&ScenarioId=11756&Type=1

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Physicianfailstoreturn
chartstocorrectshelf

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
Humanerror,distraction

Delayinscanningchart

20 Doctortogivecompleted
chartstoreceptionistto
placeoncorrectshelf

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

602

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=10146&ScenarioId=11756&Type=1

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