9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

2015MedSurgFallsFMEASSRMC
ShandsStarke
Starke,Florida,UnitedStates
HospitalCommunity

Aim:Reducetherateoffallprevalenceby50%.(Fallsperpatientday)

ProcessData
Date:03/11/2015
Step

Description

FallRiskassessment

FailureMode

Causes

Inaccuratefallrisk
assessmentleadsto
unidentifiedrisk

Inconsistenteducationto
Patientathigherriskgoes
staffmembersregardinguse unidentified
offallrisktool

Effects

Nursedoesnotgiveayellow
armband
Step

Description

NoimplementationofYellowSocks

FailureMode

Causes

Effects

Slip/trip/fall

Lackofprecautionsinplace,

noinjurytosevere

Step

Description

Technology/alarmfailures

FailureMode

Causes

Effects

Alarmsnonfunctional,not
setornotavailable

Inattention,lackofresets
followingcare,patient
tampering,devicefailure

Highriskpatientsmayhave
unintendedOOBactivity
possiblyresultinginfall,no
staffawarenessofactivity
duetodependenceonnon
functioningalarmtoalert.

AlarmnotsettoCentral
monitoring

Step

Description

FailuretoreportviaSBAR

FailureMode

Causes

Effects

Fallrisknotcommunicated

Occ Det Sev RPN Actions

5

140

10

150

Occ Det Sev RPN Actions

4

Description

MedicationInfluencesonFallRisk

140

Occ Det Sev RPN Actions

4

140 Incorporatealarmtestinto
regularrounding,review
alarmparametersand
functionaspartofroutine
patientevaluations

200 Allbedalarmswillbesetto
"CentralMonitoring"forfall
riskpatients.

Occ Det Sev RPN Actions

6

Step

108

FailureMode

Causes

Effects

Overmedicationeffectswith
newmedicationsor
unfamiliarmedicationsorin
combination

Acuteillness,paincontrol,
physiologiceffectsand
interactionswithnew
regimen

Progressivesymptomsduring
thecopurseofstayresulting
intemporaryincreaseinfall
likelihood

60

Dizziness,ataxiafalls

32

Slowedorimpaired
intreractions,timingand
judgementsiorreactionsdue combiningofmedications
tomedicationsandtimingof
administration
Step

Description

EnvironmentalConcerns

Occ Det Sev RPN Actions

FailureMode

Causes

Effects

Bedsideclutter

Lackofcontrolofpersonal
items

Slip,tripfall

Occ Det Sev RPN Actions

3

15 Vigilanceinmaintaining
order,encouragepatientsto
sendnonessentialshome

Careitemsonwheels,IV
poles,bedsidetables,
tubings,electricalcordsetc

Neccessarycareitems,
subjecttohaphazard
placement

Slip,trips,falls

15

Unfamiliarenvironment
particularlyatnight

Elderlyconfusion,low
lighting,needforbathroom
use

wandering,slips,tripsfalls

40

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19387&ScenarioId=21348&Type=1

1040

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

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=19387&ScenarioId=21348&Type=1

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