9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofNursemanagerpatientflow
WilkesRegionalMedicalCenter
NorthWilkesboro,NorthCarolina,UnitedStates
HospitalCommunity

Aim:InresponsetotheneedforCriticalCarebedsthenursemanagergroupdevelopedastrategyimplementinganalgorithmtodetermine
whichpatientsareappropriatefortransferfromtheCriticalCaresettingtoaloweracuitystatus.ByJune20150%ofpatientsinneedof
criticalcarewillbetransf
ProcessData
Date:04/15/2015
Step

Description

Patientbecomesunstablerequiringhigherlevelofcriticalcare

FailureMode

Causes

Failuretorecognizecondition Patientvolumes
change
Stafflackofassessment
education
Inappropriateinitialbed
utilization
Physiciannonresponsiveto
callsforassistance
Failureofhandoff
communicationregarding
patientcondition
Step

Description

Notificationofproviderandsupervisor

Effects
Deteriorationofpatient
condition

FailureMode

Causes

Effects

Unabletocommunicatewith
theprovider

Physiciandoesnotrespond
tocallsorbeeps
Physiciannotonpremises
Telecommunicationfailures
Physiciandoesnot
communicateplansfor
absencefromthefacility

Lackofnecessarycare
providersatpatientbedside
Furtherdeteriorationof
patientcondition

Step

Description

ICUbedavailabilityconfirmedandassignmentgiven

FailureMode

Causes

Nobedavailable

Physiciannotwillingto
Patientmanagedoutsideof
assesscurrentICUpatient
appropriatesetting
acuity
Inappropriatebedutilization
Allbedsappropriatelyinuse
Bedsclosedduetovarious
causes(staffing,equipment,
construction,etc)

Step

Description

Interventionscompletedasneeded

FailureMode

Causes

Effects

Effects

Interventionnotimplemented Noqualitiedstaffavailableto Worseningpatientcondition

performinterventions
ordeath
Lackofcommunicationfrom
physician
Equipment/medicationnot
availableorfails
Physicianunfamiliarwith
orderingandfacility
processes

Step

Description

PatienttransferredtoICU

FailureMode

Causes

Patientnottransferred

Nobedavailable
Potentialdelayintreatment
Lackofphysicianresponseto anddeclineinstatus
requestfortransferfrom
CCU
Nopatientsstabletobe

Effects

Occ Det Sev RPN Actions

8

40 staffeducation
Followcriteriaforlevelof
caredesignation
Utilizeoverheadpagingfor
physiciannotification
UseofSBARand
standardizedhandofftools

Occ Det Sev RPN Actions

9

45 Clarifyphysicianscheduling
practiceswithadministration
Discussmoreappropriate
measuresofcommunication

Occ Det Sev RPN Actions

3

24 Identifyabedaheadwhen
unitisfull
CommunicatewithICU
ChargeNurse
Initiateincidentcommand

Occ Det Sev RPN Actions

3

10

30 Developanalgorithmfor
patientflowtoensure
availability
Supervisortoassessstaffing
housewide
Physicianeducation
regardingimportanceof
communication
Haveextracartavailablein
caseoffailure
Pharmacyrespondstocode
oratrayavailablefor
emergencymedicationsafter
hours
Provideupdatesforlocums
physicianswhowork
infrequently

Occ Det Sev RPN Actions

3

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19827&ScenarioId=21774&Type=1

15 Algorithmtoensurebed
availability
Chainofcommand
Communicatephysican
responsibilityforpatientcare

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
movedfromtheunit

anddeveloppolicyfor
management
Assessavailabilityoftertiary
facilitybeds

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

154

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=19827&ScenarioId=21774&Type=1

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