9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

2009FMEA
AustinMedicalCenter
Rochester,Minnesota,UnitedStates
HospitalCommunity

Aim:YearlyFMEA
ProcessData
Date:01/13/2010
Step

Description

PatientEntersClinic

FailureMode

Causes

Effects

Pt.registeredunderwrong
name

Misspelling

Wrongchartisretrieved

72 TwoidentifiersDOBand
Name

Patientisanoshow

Various

Patientdoesn'tgettreatment

30 Confirmappointments

Step

Description

PatientSeesProviderUC/ED

Occ Det Sev RPN Actions

FailureMode

Causes

Effects

Patientgetswrongdiagnosis

Providerexamnotaccurate

Wrongtests,medications,
treatmentordered

Wrongpatient

Registrationfailstoverify
patient

Wrongchartusedforpatient
history

Step

Description

PatientisScheduledforLaborXray

Occ Det Sev RPN Actions

192 Completeexamonevery
patient,verifycorrectpatient
/chart,getinterpreterif
needed.
56 Use2identifiersupon
roomingpatient

FailureMode

Causes

Effects

Labsampleistoosmall

Notenoughbloodorurine
collected

Notalltestscanberunthat
providerordered.Patient
getsincompletecare.

42 Nurseorlabcanverify
samplesizemeetsmin
requirementsbeforeletting
patientleave.

Xray/CT/MRIscanisnot
clear

Patientmovedduringexam

Radiologyorprovidercannot
makeaccuratediagnosis

54 TechscanQCscansbefore
lettingpatientleave
radiology

Patientdoesn'tshowupfor
lab/xraytestsorF/U

Various

Notestsarecompleted

24 Bringlab/xraystaffto
examroomsopatientcan
notleavebeforetheyare
complete

Step

Description

PatientLeavesUC/ED(beforeresultsareback)

Occ Det Sev RPN Actions

FailureMode

Causes

Effects

UC/EDproviderintendsfor
patienttofollowupwith
primarycareprovider.But
patientdoesn'thaveone.

InsufficientaccesstoPC/FP

Patientwillnotgetfollowup
onresultsoftests

336 ConfirmifpatienthasaPC
provider.Ifnotsystemin
placeforUC/EDproviderto
handlefollowup.

ResultssenttoUC/ED(from
lab/rad),butcopiesdon't
print(technicalreasons)

ITissuesorwrongnumber
onfax

Resultsarenotavailablefor
providerinUC/ED

60 Visualcuestoletproviders
knowwhichpatientshave
pendingresultstheyshould
belookingfor.

HISProcessforwardsresults Providermaynotbefamiliar
toprovideroncall
withpatient

Oncallproviderbelieves
someoneelsehasfollowed
upalready.

210

Oncallproviderdoesnot
followupwhentheysee
resultscomeintotheirtask
list.

Patienthadtestsdonein
UC/EDbutresultscamein
aftertheorderingprovider
hasleftandpatienthasnot
PCprovider.Theresultsare
forwardedtooncallprovider
asataskforfollowup.

Oncallproviderhadno
contactwithpatient.Needsto
readcharttoknowhowto
interpretresultsand
determineappropriatefollow
up.Timedemandsononcall
providerarealreadyhigh,
andthisisatimeconsuming
task.

448 Redesignfollowupsystemto
reducethenumberoftasks
thatgotooncallprovider
forpatientstheydidnot
encounterorwhodonot
haveaPCprovider.Improve
PCaccess.Haveprocessto
assignPCprovidertoUC/ED
patients.

ResultsareprintedinUC/ED
afterpatientleaves.The
resultsareoverlooked.

Providersandnursesget
busy,manypapersmaybe
inthearea.

Resultsarenotactedupon

Step

Description

Patientnotadmitted/goeshome

Occ Det Sev RPN Actions

60 Systemforresultstobe
sortedanddeliveredto
nurse/providerteam.

CalculatedTotals

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=10010&ScenarioId=11602&Type=1

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

TotalRiskPriorityNumberfortheprocess

1584

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=10010&ScenarioId=11602&Type=1

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