FailureModesandEffectsAnalysis(FMEA)Tool

CopyofPresurgicalEKG
UnitedStates
HospitalOther

Aim:ReducetheRPNForpresurgicalEKGtestingby50%overthenextsixmonth
ProcessData
Date:07/23/2012
Step

Description

PresurgicalRNperformsproperativehistory

FailureMode

Causes

Effects

OmmitsCardiachistory

Poorpatienthistorian

Underlyingcardiacdisease/
historyundetected

Step

Description

CNAPerformsEKGatendofVisit

FailureMode

Causes

AbnormalEKGnotdetected
priortopatientleaving
facility

1.RNnotrequiredtoassess
Surgicaldelays
EKG
Cancelations
2.CNAnottrainedtoidentify UndiagnosedMI's
abnormalEKG

Step

Description

EKGplacedinsurgicalPacket

FailureMode

Causes

1.EKGnotpresentinEMR
1.PrescreeningAccount
2.PrimarySurgeonnotlisted numberdifferentthanDOS
asreferring
2.Busyrushedenviorment

Step

Description

PatientPresentsDOS

Effects

Effects
1.EKGnotavailableDOS
2.Cardiologyunableto
Identifypt/surgeon

FailureMode

Causes

Effects

SurgicalCancelation/delay

1.AbnormalEKGNot
detected
2.PrimarySurgeonnot
notifiedofabnormalEKG
3.Cardiologyinterpretation
notrequired

DOSCancelationDelaysdt
cardiacclearance

Occ Det Sev RPN Actions

5

30 Specificcardiachistory
questionairedeveloped

Occ Det Sev RPN Actions

6

10

180 1.PerrformEKGpriortoRN
Evaluation
2.RNmustevaluateEKG
priortoPtleavingfacility

Occ Det Sev RPN Actions

7

392 1.UtilizeMedicalrecord
number(MRN)ratherthan
accountnumberaspatient
identifier
2.Technicianperformingtest
mustentersurgeonunder
referring

Occ Det Sev RPN Actions

8

10

640 1.RNnotifysurgeonofall
AbnormalEKG
2.Cardiologyrequiredto
readallpreoperativeEKG
within24hours
3.Surgicalclearanceby
cardiloogypriortoDOS

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

10=VerylikelyitWILLNOTbedetected

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

Annotation
Event:Processproblemnoted

1242