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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
FailureModesandEffectsAnalysis(FMEA)Tool
RRTsatNHS
NorthwestMedicalCenter
Springdale,Arkansas,UnitedStates
HospitalTeaching
Aim:IncreasestaffawarenessofwhentocallRRTandpreventCodeBlue'soutsideofIntensiveCare
ProcessData
Date:04/22/2010
Step
Description
Staffrecognizessymptomstoreport
FailureMode
Causes
Effects
Staffnoteducatedon
procedure
72 Continueeducationtoall
staffnurses
Cardsgiventoallstaff
nurseswithindicatorslisted
Orientation&cardsgivento
allnewemployees
MonitorunplannedICU
transfersandoutofICU
codesmontlytotrack
12
Currentwayofdoingvital
signs/assessmentsdon't
supporttimelyinterventions
Step
Description
NurseconsultsChargeNurse/TeamLeader/AdminSupervisorbefore
RRT
Step
Description
Attendingcaregivernotifiesoperatortopageteam
FailureMode
Causes
Effects
Teamforgetstocallinto
notifyoperatorwhoistobe
called
Step
Description
Teamnotified
Causes
Overheadpagingnotheard
byalliedhealthstaff.
Ifstaffinareaswhere
Delayedresponsetopatient
overheadpagingisnotclear. room.
Effects
2callswithinabriefamount
oftime
Step
Description
Physiciannotification
FailureMode
FailureMode
Causes
Effects
120 MonitoroutofICUcodesand
unplannedtransfers
10
60 OperatortocallICU,ERor
311/117supervisorifno
onecallsinforashifttofind
outwhoresponderis
108 Educatestafftousepagersif
neededtocommunicatewith
RRT
10
100 Operatortotransfercallto
RRTRNandthatRNwill
triage
Teamforgetstonotify
physician
10
10
100 Teameducatedtonotify
physicianonallcalls
Physiciansveryconcerned
abouttimely
notificaiton/Physiciandoesn't
returncallswithfirstbeep
10
10
300 Areaaddedto
documentationformfor
beeped/timereturncall
Willtrackwithmonthlydata
attendingphysician,called
physicianandresponse
timestopresenttophysician
groups
Step
Description
Teamrespondstofloor
FailureMode
Causes
Effects
Equipmentneedednot
complete
Inexperienceofunitto
prepareforteamresponse
delayininterventions
10
40 Staffeducatedtohave
equipmentavailableforRRT
BPcuffmissingfromkit
10
30 ALLBPcuffswillbelabeled
RRTbySPD
IFbincomesbacktoSPD
withoutBPcuffinitSPDto
notifyteam
Documentationformsmissing
10
30 CNSgroupwillcheck
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=10387&ScenarioId=12167&Type=2
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9/14/2015
InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
clipboardsmonthlytomake
sureadequate
documentationformsin
them
RRTtoobusy/forgetsto
replacesuppliesused
Step
Description
RRTtakesaction
Teaminexperience,obstacles Insufficientsuppliesinthe
togettingsuppliesafter
eventofanotherRRTin
hours
sameshift
10
80 Havebackupsupplies
availableafterhoursandon
weekends
CalculatedTotals
TotalRiskPriorityNumberfortheprocess
1052
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=10387&ScenarioId=12167&Type=2
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