9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

UIHCBurnUnit:PatientEducationDocumentation
TheUniversityofIowaHospitals:BurnUnit
IowaCity,Iowa,UnitedStates
HospitalTeaching

Aim:ReducetheRPNforPatientEducationDocumentationprocessontheUIHCBurnunitby70%in3months
ProcessData
Date:06/18/2012
Step

Description

PatientEducationScreening(within24hoursofadmission)

FailureMode

Causes

Effects

Nursesfailtocomplete
educationscreeningwith24
hoursofpatientadmission.

1)Nurseisbusywithother
patients.
2)Nurseforgottocomplete
screening.
3)Nurseisnotawareof
24hrprotocolforcompletion
ofeducationscreening.
4)Nursefeelsburdenedby
documentationprocess
(negativeattitude).
5)Nursedoesnotranked

1)Theinitiationofpatient
educationisdelayed,which
furtherslowseducation
processesthroughoutlength
ofstay.
2)Patientsarenot
interviewedtoobtainpatient
orfamilypreferenceson
educationneedsfailstobe
patientcentered.
3)Thescreeni

Step

Description

CompletingtheElectronicEducationPlan:Step1=AddingAdmission
template:"Education(adult/peds)"

FailureMode

Causes

Effects

Nursesfailtoaddthe
AdmissionEducation
template"Education
(adult/peds)"tothe
electronicEducationPlan.

1)Nursedoesnothave
adequateEPICtraining
unawareofhowtoaddtitles.
2)Nurseforgottocomplete
screening.
3)Nurseisnotawareof
protocolforaddingthe
admissioneducation
template.
4)Nursefeelsburdenedby
documentationprocess
(negative

1)Failstomeetstandardunit
protocolinplacetoensure
patientsafetyandquality
educationtoproducebest
outcomes.
2)Admissioneducationwill
nothaveatemplateavailable
forroutinedocumentation,
unlessanothernurse
completesit.

Step

Description

CompletingtheElectronicEducationPlan:Step2=Addingproblem
specifictemplate:"Burn"

FailureMode

Causes

Effects

Nursedoesnotaddinthe
"Burn"educationtemplate.

1)Onlythe"Education
(adult/peds)"templatewas
enforcedinthepast.
2)Nursedoesnothave
adequateEPICtraining
unawareofhowtoaddtitles.
3)Nurseforgottocomplete
screening.
4)Nurseisnotawareof
protocolforaddingthe
admissioneducat

1)Patienteducationplanwill
notbesufficienttomeet
standardsforcompleteness.
2)Educationplanwillnot
addressburnspecificinjury
andeducation.
3)Ineffectiveeducation
topicscoveredmayleadto
increasedlengthof
stay/readmissionafterdi

Step

Description

CompletingtheElectronicEducationPlan:Step3=Addingadditional
patientspecifictemplates

FailureMode

Causes

Effects

Nursewillnotaddoptional
patientspecifictemplates

Nursedoesnothave
adequateEPICtraining
unawareofhowtoaddtitles.
2)Nurseforgottoaddtitles
3)Nursefeelsburdenedby
optionaldocumentation
process(negativeattitude).
4)Addingtemplateis
optional.
5)Nursedoesnotrank
educationasa

1)Patienteducationplanwill
notbesufficienttomeet
standardsforcompleteness.
2)Educationplanwillnot
addressproblemspecificor
patientcenterededucation
needs.
3)Ineffectiveeducation
topicscoveredmayleadto
increasedlengthofstay/re

Step

Description

ConsistencyinDocumentation:Dailydocumentationwithnursingnote
perentry

FailureMode

Causes

Effects

Occ Det Sev RPN Actions

5

80 1)Hang"Education
Screeningcompleted?"signs
inpatientroomstoremind
nursestocomplete
immediatelyuponadmission.
2)Addalertstoremindnurse
tocompleteanddocument
screenwithinallEHRs.
3)Havenurseleaders
conductroutine
documentationau

Occ Det Sev RPN Actions

9

360 1)Hang"PatientEducation
Documented?"signsin
patientroomstoremind
nursestocomplete
immediatelyuponadmission.
2)Addalertstoremindnurse
tocompleteanddocument
withinallEHRs.
3)Havenurseleaders
conductroutine
documentationauditsto

Occ Det Sev RPN Actions

3

54 1)Hang"PatientEducation
Documented?"signsin
patientroomstoremind
nursestocomplete
immediatelyuponadmission.
2)Addalertstoremindnurse
tocompleteanddocument
withinallEHRs.
3)Havenurseleaders
conductroutine
documentationauditsto

Occ Det Sev RPN Actions

2

108 1)Hang"PatientEducation
Documented?"signsin
patientroomstoremind
nursestocomplete
immediatelyuponadmission.
2)Addalertstoremindnurse
tocompleteanddocument
withinallEHRs.
3)Havenurseleaders
conductroutine
documentationauditsto

Occ Det Sev RPN Actions

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=13972&ScenarioId=15944&Type=1

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

Dailydocumentationwillnot
occur,oranursingnotewill
notbecompletedwitheach
educationentry.

1)Nurseisbusywithother
patients,anddidnothave
timetodocumentdaily.
2)Nurseforgottodocument
thenewprotocolfora
nursingnote.
3)Nurseisnotawareofthe
protocolfordaily
documentationwiththe
additionofanursingnote.
4)Nur

1)Nursingnotewilldecrease
effectivenessanddepthof
electroniccommunication
acrossandbetweencare
disciplines.
2)Patienteducationplanwill
notbesufficienttomeet
standardsforconsistency
andmayposeincreasedrisk
formalpracticeasares

54 1)Hang"PatientEducation
Documented?"signsin
patientroomstoremind
nursestocomplete
immediatelyuponadmission.
2)Addalertstoremindnurse
tocompleteanddocument
withinallEHRsDAILYAND
WITHNURSINGNOTE.
3)Havenurseleaders
conductrout

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

656

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=13972&ScenarioId=15944&Type=1

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