9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofPrescriptionRefill/Gray
UnitedStates
HospitalTeaching

Aim:Myaimistoimprovetheprescriptionrefillprocessintheoutpatientclinic
ProcessData
Date:10/02/2011
Step

Description

Patientphonesinrequestformedicationrefillandleavesmessageon
phoneline

FailureMode

Causes

Effects

Messagenotleftoncorrect
providersphone

Wrongnumbercalled
Elderlyorconfusedpatient

Medicationnotrefilled

Step

Description

Phonerequestissenttoclinicnursetohandle

FailureMode

Causes

Effects

Informationsenttowrong
clinicnurseviaEMRsystem

Distraction
Unfamiliarwithwhatnurse
handleseachprovider
Informationconveyedby
clericalstaffthatmaynotbe
awareofwhothepatient
sees

Delayinrefillsordered
Norefillsordered

Step

Description

EMRnotificationofmedicationrefillrequest

FailureMode

Causes

Notificationsenttowrong
nurse
Nursemustthenforwardto
correctperson
NursenotcheckingherEMR
messageshourly

NonotificationonEMRwhen Delayinmedicationrefill
amessageforrefillrequest
exists
Staffbusyandnotchecking
forrefillshourlyasproposed

Step

Description

Clinicnurseverifiesmedicationagainstpatientchart

FailureMode

Causes

Incorrectpatientname
Incorrecttranscriptionof
spelling,incorrectMRN,
message
incorrectmedicationname
Medicationsnotreconciled
anddose,
Medicationsnotreconciled
witheachvisittoupdatelists
Step

Description

Medicationrefillphonedin/electronicallysent

Effects

Effects
Patientmaybetakingwrong
medications,
Delayinrefills

FailureMode

Causes

Medicationrequestsnot
handledwithin48hoursas
perpolicy

Nursedidnotcheckrefill
Delayinpatientreceiving
requestonEMR,
medicationswhichcouldlead
Incorrectmedicationrequest toseriousconsequences
Pharmacynumbernotlisted

Effects

Occ Det Sev RPN Actions

4

192 Witheachofficevisitreview
medicationswithpatientand
askifrefillsneeded,give
contactnumbertopatientat
endofvisit

Occ Det Sev RPN Actions

3

108 Limitingofstaffthathandles
prescriptionrefills

Occ Det Sev RPN Actions

5

90 Dedicatednurseforeach
coregroupofprovidersthat
willreceiveallrequestsfor
refills

Occ Det Sev RPN Actions

4

144 Correctpatientnameand
MRN
Correctlistofmedications
requested
Updatedmedreconciliation
witheachvisit

Occ Det Sev RPN Actions

5

125 Updatedmedication
reconciliation
Correctphonenumber/fax
numberforpharmacy
Dedicatednurseforrefillsfor
subgroupofspecialty
providers

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

659

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=13144&ScenarioId=14981&Type=1

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