2013 fall fmea
DESCRIPTION
hTRANSCRIPT
9/14/2015 Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=15198&ScenarioId=17336&Type=1 1/1
Failure Modes and Effects Analysis (FMEA) Tool
2013 Fall FMEA
IASIS health careSt Petersburg, Florida, United StatesHospitalCommunity
Aim: Decrease anticipated falls by 30% in 60 Days
Process Data
Date: 03/29/2013
Step Description1 Admission Assessment
Failure Mode Causes Effects Occ Det Sev RPN ActionsFall Assement not completed Staff failure No fall precautions
implemented5 9 10 450 Computer Hard Stop for Fall
Assessment
Step Description2 Interventions
Failure Mode Causes Effects Occ Det Sev RPN ActionsFall interventions notimplemented
Staff lack of knowledge ofavailable interventions Stafffailure to implement
High Risk patients notproperly protected
9 9 10 810 Staff education FallRounding
Step Description3 Hand off communications
Failure Mode Causes Effects Occ Det Sev RPN ActionsReport to oncoming staffinadequate
Failure to add to care plan failure to give proper report
Fall precautions diminish oversubsequent shifts
5 2 10 100 Bedside Report Fallrounding
Step Description4 Ancillary Care
Failure Mode Causes Effects Occ Det Sev RPN ActionsSafety devices removed Failure of Ancillary Staff to
Reimplement fall safetydevices when removing orreturning a patient to theroom
Pt left unprotected 8 2 10 160 Educate all ancillary staff onneed to reimplement fallsaftey devieces
Calculated Totals
Total Risk Priority Number for the process 1520
Occ: Likelihood of Occurrence (110)Det: Likelihood of Detection (110) NOTE: 1 = Very likely it WILL be detected
10 = Very likely it WILL NOT be detectedSev: Severity (110)RPN: Risk Priority Number (Occ × Det × Sev)
AnnotationNone