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  • Scenario Hospital Recent

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    6 visualizações1 página

    Scenario Hospital Recent

    Enviado por

    Anisa
    o[[[[[[[[[[[

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 1

    9/14/2015

    InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

    FailureModesandEffectsAnalysis(FMEA)Tool

    ScenarioHospital
    ScenarioHospital
    Wells,Maine,UnitedStates
    HospitalCommunity

    Aim:Reducetheriskofdeathafterpatientsedationby100%inthreemonths.
    ProcessData
    Date:06/24/2014
    Step

    Description

    Assesspatient

    FailureMode

    Causes

    Effects

    Inaccuratepainassessment

    Culturalinfluences,patient
    unabletoarticulate

    Poorpaincontrol

    Step

    Description

    Chooseanalgesic/sedationmedication

    FailureMode

    Causes

    Wrongmedicationselected

    Tolerancetomedicationsnot Improperdosing.
    considered.
    Concomitantuseofother
    analgesicsnot
    considered.Knowledge
    deficit.

    Step

    Description

    Prescribeanalgesic/sedationmedication

    Effects

    FailureMode

    Causes

    Effects

    Wrongdose

    Knowledgedeficit.Wrong
    medicationselection.
    Informationaboutthedrug
    notavailable.

    Overdose.

    Step

    Description

    Monitoreffectsofmedication

    FailureMode

    Causes

    Effects

    Insufficientmonitoringof
    sedationmedicationeffects.

    Workload,knowledgedeficit,
    monitoringparametersnot
    ordered,ineffective
    communicationbetween
    caregivers.Protocolsnot
    followed

    Failuretorecognizethe
    consequencesofsedation
    beforepatientharmoccurs.
    Inabilitytorecognize
    changesinpatient's
    condition.

    Occ Det Sev RPN Actions


    2

    64 Standardscaletohelp
    assesspain.Cultural
    influencestraining.

    Occ Det Sev RPN Actions


    4

    10

    120 CPOEwithdecisionsupport.
    Clinicalpharmacyprogram.
    Pointofuseaccesstodrug
    information.

    Occ Det Sev RPN Actions


    4

    10

    120 CPOEwithdecisionsupport.
    Clinicalpharmacyprogram.

    Occ Det Sev RPN Actions


    3

    10

    90 Standardordersetswith
    monitoringguidelines.
    Properstaffingpatternsand
    safeworkload.Standardized
    documentationwithredflags
    builtintoalertstaffof
    abnormalV/Sorsedation
    levels.

    CalculatedTotals
    TotalRiskPriorityNumberfortheprocess

    394

    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=17772&ScenarioId=19917&Type=2

    1/1

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