9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

ReducingICPDuringAirMedicalTransportinanE
UnitedStates
Other

Aim:Reduceincidenceofincreasedintracranialpressure(ICP)intraumaticbraininjuredpatientswhoaremedicallyairtransportedby50%
within6monthsbyfollowingtheICPpreventionplan.

ProcessData
Date:04/16/2014
Step

Description

Elevatingheadofbed3545degrees

FailureMode

Causes

Effects

Medicalflightcrewfailsto
recognizesignsand
symptomsofICP,doesnot
elevateheadofbed35to45
degrees,causingfurther
increaseofICPinthe
traumaticbraininjured
patient

Thoroughassessmentnot
done,distractionfrompatient
care,notrecognizingICP
signsandsymptoms

InthepatientwithICP,ifthe
headofbedisnotelevated
35to45degrees,further
increaseinintracranial
pressurewillcontinue,
furtherincreasingbrain
damage,increasingmorbidity
andmortality

Step

Description

Maintainbloodpressuregreaterthan90systolic

FailureMode

Causes

Effects

Medicalflightcrewdoesnot
recognizelowbloodpressure
hasanegativeeffecton
patientswithICP

Medicalflightcrewdoesnot
properlyreassesspatient's
bloodpressureduringflight
ordoesnotunderstandthe
implicationsofalowerblood
pressureontraumaticbrain
injuredpatientswithICP

Systolicbloodpressureless
than90causesICPto
increasefurtherdueto
hypoperfusionofthebrain,
vasodilationofthevesselsin
thebrain,whichinturn
causesincreasedICPtothe
traumaticbraininjured
patient,increasingriskfor
mortalityandm

FailureMode

Causes

Effects

Inadequateairway
managementcanleadto
increasedmortalityand
morbidityby10fold,
increasebraininjury,and
causementalandphysical
disabilityinthetraumatic
braininjuredpatient

Medicalflightcrewmaybe
uncomfortabletakingcontrol
oftheairwaybyrapid
sequenceintubation,maynot
recognizetheimportanceof
maintainingtheairwayina
traumaticbraininjured
patient,doesnotrecognize
signsandsymptomsofICP
duetoinadeq

Medialflightcrewneedsto
reassessfrequently,
recognizesignsand
symptomsofincreasingICP
duetoinadequateairway
control,beconfidentintheir
abilitytogainandmaintain
airwaycontrol

Step

Description

Controlairway

Occ Det Sev RPN Actions

5

125 Performthorough
assessment,evaluate
mechanismofinjury,elevate
headofbed35to45
degreeswhileintransport

Occ Det Sev RPN Actions

5

125 Reassesspatientfrequently,
monitorBPevery5minutes
inpatientswithICP,and
providesupportand
medicationstoensurea
systolicbloodpressureof
greaterthan90

Occ Det Sev RPN Actions

8

10

480 Practiceairwaymanagement
skillsquarterly,thoroughly
assesspatientatfrequent
intervals,maintainairway
withrapidsequence
intubationearlyon,provide
hyperventilationtokeepend
tidalCO2at25to30during
airtransport

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

730

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=17336&ScenarioId=19484&Type=1

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