9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

RCC/PACU
SurgicalCenterofGreensboro
Greensboro,NorthCarolina,UnitedStates
Other

Aim:Reducetheriskofexposuretobloodbornepathogens
ProcessData
Date:11/12/2009
Step

Description

Purchasingneedlesforprocedures

FailureMode

Causes

Effects

Incorrectneedlepurchased

Backorderorerrorin
ordering

Increasedriskofexposure
duetoincorrecttypeof
needleordered

Step

Description

Needlesstoredinbulkstorage

FailureMode

Causes

Effects

Boxesofneedlesleftin
unsecuredarea

Needleswerenotputaway
properlybystaff.

Unauthorizedpersonnelcan
gainaccess

Step

Description

Needlestransportedtodepartmentsandstored

FailureMode

Causes

Incorrectneedletakentothe Notcheckingcontainerfor
department
properneedle

Effects
Possibilityusinganimproper
needle

Step

Description

syringecapremoved,medicationdrawnupandneedlerecappedand
syringelabeled

FailureMode

Causes

Possibleneedlestickdrawing Beinginahurryorbeing
upmedicationandwhen
distractedandnotusing
recappingneedle
propertechnique
Step

Description

syringecarriedtopatientsbedside

Effects
Increasedriskofexposure
duetoimpropertechnique

FailureMode

Causes

Needlecapnotsecure

Notcheckingthatneedlecap Increasedriskofsharps
issecurebeforegoingto
injuryandcontaminationof
patientsbedside
needle

Step

Description

capremovedandmedicationadmnistered

Effects

FailureMode

Causes

Effects

Possibilityofsharpsinjury
whencapisremoved

Impropertechnique

Sharpsinjuryand
contaminationofneedle

Step

Description

syringeandneedleplacedinsharpscontainerifcomplete

FailureMode

Causes

Effects

Sharpscontaineristoofull

Contanernotproperly
changedaccordingtopolicy

Sharpsinjury

Step

Description

ifproc.requiresmoremed.thenneedleisrecappedperonehanded
tech.thendiscardedinsharpscon

FailureMode

Causes

Effects

Missingneedlecapandnot
recappingneedleproperly

Beinginahurryorbeing
distracted

Sharpsinjury

Step

Description

Whensharpscont.nearfullplaceinhwb

FailureMode

Causes

Possibleneedlestickif
containernotcarried
properlyornotdisposed

Containernotclosedproperly Sharpsinjury
orcarryingcontainer
improperly

Effects

Occ Det Sev RPN Actions

2

10

160 Recheckifonbackorderand
havestaffevaluateneww
needleforsafety

Occ Det Sev RPN Actions

3

168 Makesureanysharpsand
needlesarestoredproperly
behindlockeddoors.

Occ Det Sev RPN Actions

5

80 Makesuretodoublecheck
needlecontainer

Occ Det Sev RPN Actions

7

280 Removealldistractionssoas
tofocusonusingproper
technique

Occ Det Sev RPN Actions

2

12 Recheckandmakesure
needlecapissecure

Occ Det Sev RPN Actions

7

392 Usepropertechnique

Occ Det Sev RPN Actions

8

10

640 Makesuresharpscontainer
notfullwhendisposing
needle

Occ Det Sev RPN Actions

5

10

100 Takeyourtimeanduse
propertechnique

Occ Det Sev RPN Actions

6

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9738&ScenarioId=11272&Type=1

10

120 Makesuresharpscontainer
isclosedproperlyand
transportedproperly

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

immediatelyinhwb
Step

Description

10

HWB'aresealedandremovedbySteriCycleweekly

FailureMode

Causes

Effects

HWBnotsealedproperly

HWBtoofull

Sharpsinjury

Occ Det Sev RPN Actions

2

32 MakesureHWBisnottoo
full

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1984

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=9738&ScenarioId=11272&Type=1

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