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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
FailureModesandEffectsAnalysis(FMEA)Tool
CopyofNursemanagerpatientflow
WilkesRegionalMedicalCenter
NorthWilkesboro,NorthCarolina,UnitedStates
HospitalCommunity
Aim:InresponsetotheneedforCriticalCarebedsthenursemanagergroupdevelopedastrategyimplementinganalgorithmtodetermine
whichpatientsareappropriatefortransferfromtheCriticalCaresettingtoaloweracuitystatus.ByJune20150%ofpatientsinneedof
criticalcarewillbetransf
ProcessData
Date:04/15/2015
Step
Description
Patientbecomesunstablerequiringhigherlevelofcriticalcare
FailureMode
Causes
Failuretorecognizecondition Patientvolumes
change
Stafflackofassessment
education
Inappropriateinitialbed
utilization
Physiciannonresponsiveto
callsforassistance
Failureofhandoff
communicationregarding
patientcondition
Step
Description
Notificationofproviderandsupervisor
Effects
Deteriorationofpatient
condition
FailureMode
Causes
Effects
Unabletocommunicatewith
theprovider
Physiciandoesnotrespond
tocallsorbeeps
Physiciannotonpremises
Telecommunicationfailures
Physiciandoesnot
communicateplansfor
absencefromthefacility
Lackofnecessarycare
providersatpatientbedside
Furtherdeteriorationof
patientcondition
Step
Description
ICUbedavailabilityconfirmedandassignmentgiven
FailureMode
Causes
Nobedavailable
Physiciannotwillingto
Patientmanagedoutsideof
assesscurrentICUpatient
appropriatesetting
acuity
Inappropriatebedutilization
Allbedsappropriatelyinuse
Bedsclosedduetovarious
causes(staffing,equipment,
construction,etc)
Step
Description
Interventionscompletedasneeded
FailureMode
Causes
Effects
Effects
Step
Description
PatienttransferredtoICU
FailureMode
Causes
Patientnottransferred
Nobedavailable
Potentialdelayintreatment
Lackofphysicianresponseto anddeclineinstatus
requestfortransferfrom
CCU
Nopatientsstabletobe
Effects
40 staffeducation
Followcriteriaforlevelof
caredesignation
Utilizeoverheadpagingfor
physiciannotification
UseofSBARand
standardizedhandofftools
45 Clarifyphysicianscheduling
practiceswithadministration
Discussmoreappropriate
measuresofcommunication
24 Identifyabedaheadwhen
unitisfull
CommunicatewithICU
ChargeNurse
Initiateincidentcommand
10
30 Developanalgorithmfor
patientflowtoensure
availability
Supervisortoassessstaffing
housewide
Physicianeducation
regardingimportanceof
communication
Haveextracartavailablein
caseoffailure
Pharmacyrespondstocode
oratrayavailablefor
emergencymedicationsafter
hours
Provideupdatesforlocums
physicianswhowork
infrequently
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19827&ScenarioId=21774&Type=1
15 Algorithmtoensurebed
availability
Chainofcommand
Communicatephysican
responsibilityforpatientcare
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9/14/2015
InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
movedfromtheunit
anddeveloppolicyfor
management
Assessavailabilityoftertiary
facilitybeds
CalculatedTotals
TotalRiskPriorityNumberfortheprocess
154
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=19827&ScenarioId=21774&Type=1
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