9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

Providercommunicationincriticalcare
UnitedStates
HospitalOther

Aim:Improvecommunicationamonghealthcareprovidersandtheinterdisciplinaryteamtoimprovecoordinationofpatientcare,outcomes,and
satisfaction.
ProcessData
Date:04/14/2015
Step

Description

Grandroundstakeplaceatbedsideoraroundpatient'sroom.

FailureMode

Causes

Effects

Grandroundsareskipped.

Lackoftime
Lackofcoordinationofteam
Patientacuitydemands
interfere.

Nocoordinationofcare.
Noupdatesfor
interdisciplinaryteam.
Mayveerofftrackofdaily
caregoals.
Concernsmightgoun
addressed.

Step

Description

Attendingphysician,nurse,chargenurse,pharmacist,andrelevant
personnelattend.

FailureMode

Causes

Oneormorepertinent
membersdonotattend.

Timeconflicts,workabsence. Maylackcomprehensive
patientreviewandinputon
goalsfortheday.

Effects

Step

Description

Bedsidenursegivesbriefupdateofpatient'sclinicalcondition.

FailureMode

Causes

Effects

Nurseomitsimportant
information.

Forgets.
Wasnotinformedby
previousshift.
Interruptionsinrounds.

Potentialformajorissuesto
gounaddressed.

Step

Description

Bedsidenurseannouncesanyconcernsfromnurse,patient,orfamily
forteamtoaddress.

FailureMode

Causes

Effects

Pointofconcernomittedor
unheardbyteam.

Interruptions,nurseforgets,
membersdistracted.

Patient/familyconcerngoes
unaddressed.
Decreasedpatient/family
satisfaction.

Step

Description

Physicianstatesanypertinentinformation,criticalordersand
interventions.

FailureMode

Causes

Effects

Inadequateorincorrect
orders.

Confusion,lackofclarity
regardingpatientsituation,
lackofknowledge,
assumptionthatanother
providerwilladdress.

Delayinclinical
improvement,deterioration
ofpatientcondition,death.

Step

Description

Teamagreesonshorttermandlongtermgoalforpatientcare.

FailureMode

Causes

Effects

Stepomitted.

Personalpreferences,
difficultyofpatient'sclinical
situation.

Delayinpatient'sclinical
progression,lengthened
hospitalstay,lackofclarity
onplanofcare.

Step

Description

Teammembersgiveinputonstepstoachievestatedgoal.

FailureMode

Causes

Effects

Stepomittedbyallorpartof Absenceofoneormore
Delayinachievinggoals,
team.
teammembers,lackofinput. lengthenedhospitalstay,
morecostlycare.

Occ Det Sev RPN Actions

3

15 Assigngeneraltimefor
grandroundstostartforthe
criticalcareunit.Limiteach
roundtofiveminutes.Send
reminderseverymorningto
participantsaboutrounding.
Auditrateofimplementation
inthebeginning.

Occ Det Sev RPN Actions

5

15 Scheduledgrandrounds
daily,sendremindersto
pertinentmembers.

Occ Det Sev RPN Actions

3

105 Createchecklistforgrand
rounds,haveeachshift
updatechecklistwith
pertinentinfo.

Occ Det Sev RPN Actions

3

72 Addissuestochecklistas
theyarise.

Occ Det Sev RPN Actions

1

18 Teamagreesuponplanof
caretogether,ensureeach
concernisaddressed,
verbalizewhoisresponsible
forwhat.

Occ Det Sev RPN Actions

3

9 Addthisaspartofchecklist,
onepersondesignatedto
askandclarifygoalsifnot
addressedby
team/physician.

Occ Det Sev RPN Actions

3

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19603&ScenarioId=21544&Type=2

9 Ifonememberdoesnot
offerinputthatisnecessary,
physicianshouldaskthem.
Partofchecklist.

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

Step

Description

Verbalization/agreementonwhatproviderisresponsibleforvarious
aspectsofpatientcare/orders.

FailureMode

Causes

Effects

Stepomittedor
incompletely/incorrectly
addressed.

Timeconstraints,physician
forgets,confusiononwhois
responsible.

Ordersgetmissed,gapsor
overlapsincare,overriding
oforders.

Step

Description

Pertinentinformation,criticalinformation/orders,andissuestobe
addressedareplacedinEHR.

FailureMode

Causes

Effects

Occ Det Sev RPN Actions

3

Occ Det Sev RPN Actions

NotplacedinEHRaftergrand Timeconstraints,nurse
rounds,ornotcomplete.
forgets.

Majorissuesgounnoticed,
criticalinformationnot
communicatedtocareteam,
errorsinpatientcare.

Checklist/criticalinformation
isignored/missedbya
providerorcareteam
member.

Ordersmissed,delayincare,
delayinclinicalprogression,
gapsoroverlapincareand
overridingofimportant
orders,patientharm.

10

Personaldecision,
distractionsorinterruptions,
timeconstraints.

Step

Description

10

ChecklistisvisibletoallprovidersinEHR,expectationsareconveyed
clearly.

81 Assignresponsibleprovider
foreverycritical
concern/issueaddressed,
communicatethisinEHR.
Step9.

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19603&ScenarioId=21544&Type=2

32 Duringtrial,audit
implementationintoEHR,
ancillarystafftosupport
nursingstafftoallowtime
forthis.
90 PlaceinEHRsoeasilyvisible
partofpatient'schart,link
partsofchecklistto
responsibleproviderstask
list,EHRtocomparenew
ordersagainstregulationsin
thischecklist,alertproviders
ofpotentialconflicts.

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