4th floor, chest pain

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=19477&ScenarioId=21431&Type=1 1/4

Failure Modes and Effects Analysis (FMEA) Tool

4th floor, Chest pain

United StatesHospitalCommunity

Aim: Improve transfer time for STEMI patients on the 4th floor.

Process Data

Date: 03/26/2015

Step Description1 Recognize signs and symptoms of AMI

Failure Mode Causes Effects Occ Det Sev RPN ActionsPatient doesn't verbalize 1. Decreased LOC

2. Doesn't want to bother thenurse 3. Called before with noresponse 4. Pt doesn't know

5 10 10 500

Symptoms are not classic 1. Lack of knowledge 2. Female 3. Diabetic

8 10 10 800

Patient labeled a drug seeker 1. multiple pain admits 2. hx of drug abuse

5 10 10 500

Nurse doesn't recognizesymptoms

1. lack of knowledge 2. Odd symptoms

4 5 10 200

Nurse blows it off 1. lack of knowledge 2. Understaffed 3. Numerous prior complaints

3 10 10 300

Step Description2 Assessment by RN including vital signs

Failure Mode Causes Effects Occ Det Sev RPN ActionsNurse does not do one 1. Understaffed

2. Multiple sick patients1 9 9 81

Delay 1. Off floor with anotherpatient 2. Communication thinkingsomeone else was handling.

3 9 9 243

Faulty equipment 1. Dynamap broken 2. Biomed out of date

2 9 9 162

Lack of equipment 1. Missing dynamap 2 9 9 162

Assessment is within normallimits

1. silent MI 2. Symptoms not bad enoughyet

5 6 7 210

Telemetry 1. No one monitoring 2. ICU busier during day shift

3 7 7 147

Step Description3 Call the physician

Failure Mode Causes Effects Occ Det Sev RPN ActionsCan't get in touch 1. no answer

2. asleep7 10 10 700

doesn't call back didn't get the message 8 10 10 800

call service 1. lack of 2. they don't know who is oncall

7 10 10 700

Delay 1. going through office tospeak with MD 2. On hold 3. Numerous prompts

9 10 10 900

"I'm not on call" 1. Out of time frame 2. Didn't know he/she was oncall

5 10 10 500

Reading call schedule Changes Q15m 9 5 8 360

Fear of calling new nurse MD has yelled before

2 8 8 128

MD is on the way Previous knowledge that MDwill be here soon

2 8 8 128

Inconsistant ways to reachMD

Each MD does it differently 10 9 8 720

Step Description



4 Order an EKG

Failure Mode Causes Effects Occ Det Sev RPN ActionsRT not called for stat EKG 1. Didn't know to call

2. Didn't know number 3. Operator didn't answer 4. Beeper malfunction

1 9 10 90

Order doesn't print 1. Printer broken 2. Out of paper 3. Jammed

4 8 6 192

No one is available to seeprinted order

1. Staff out of department 6 10 6 360

Didn't get an order 1. MD didn't order 2. MD hasn't called back

8 10 6 480

Ordered incorrectly 1. Multiple ways to order 2. Ordered on wrong patient 3. Not stat

2 9 6 108

Step Description5 Order stat cardiac enzymes

Failure Mode Causes Effects Occ Det Sev RPN ActionsNurse didn't call Lab Nurse didn't know to call for

stat lab draws2 5 9 90

Order doesn't print to lab Printer broken, out of paper,or jammed

4 5 6 120

No one available to seeprinted order

Staff out of department 8 6 9 432

Didn't get an order MD didn't order Haven't spoken with MD

4 9 8 288

Ordered incorrectly Multiple ways to order,ordered on wrong patient,not ordered stat.

2 9 6 108

Step Description6 Establish IV access

Failure Mode Causes Effects Occ Det Sev RPN ActionsDidn't get an order from theMD

Haven't spoken with MD yet 1 1 1 1

Poor Access Dialysis Steroid use Obese Blood thinners IV drug user

4 10 10 400

Delay Inexperienced nurse Low supply cart stock

3 4 6 72

Step Description7 Draw cardiac enzymes

Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay Did not receive order

Did not receive call With another patient

6 6 9 324

Difficult stick Poor access 3 4 8 96

Step Description8 Administer NTG sl x 3 doses

Failure Mode Causes Effects Occ Det Sev RPN ActionsNo order Haven't spoken to MD 9 10 7 630

VS out of limit BP low 4 6 5 120

Delay Not in pyxis Not in eMAR

6 9 6 324

Step Description9 RT @ bedside for EKG

Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay No order

No Call With another patient

5 10 10 500

Equipment Failure malfunction 1 10 10 100

Step Description10 Place on oxygen if needed

Failure Mode Causes Effects Occ Det Sev RPN ActionsNo order MD did not order

MD hasn't call back8 8 10 640

O2 sat WNL Symptoms not affectingbreathing pattern or O2 sat

8 7 10 560

Step Description11 On call physician will come to the hospital, read the EKG, and



evaluate the patient

Failure Mode Causes Effects Occ Det Sev RPN ActionsHe doesn't come Refuses to come

Hasn't called back Says "not on call"

10 10 10 1000

Delay Not in the hospital far commute seeing other patients no sense of urgency

10 10 10 1000

Step Description12 If it is a STEMI, then MD will peer to peer transfer to ECM

Failure Mode Causes Effects Occ Det Sev RPN ActionsDoc can't get in touch withECM doc

Busy nights weekends

1 8 10 80

Doc doesn't see STEMI lack of knowledge 2 3 10 60

Delay Unsure who to call Unsure what number to call Going through multiplepeople to get connected tothe correct person

3 2 10 60

Step Description13 If it is a NSTEMI, then wait for cardiac enzymes to result

Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay Long processing time

Need recollect9 9 6 486

Step Description14 Call EZ transfer

Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay Don't know the number 2 10 9 180

EZ can't get in touch withECM

Busy Not answering phone Don't know who to call

2 2 9 36

EZ can't get roomassignment

ECM full 1 2 6 12

Step Description15 Administer Aspirin

Failure Mode Causes Effects Occ Det Sev RPN ActionsDoc didn't order lack of knowledge

Haven't spoken to doc6 8 6 288

Delay Not in pyxis Not in eMAR

4 5 2 40

Not given busy with tx allergy forgot pt with n/v

2 6 6 72

Step Description16 Fax facesheet to EZ transfer

Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay doesn't know the number

Doesn't know how to use thefax machine

2 3 2 12

Doesn't fax the facesheet Faz machine malfunction No time doesn't know they need tofax the facesheet

1 6 2 12

Step Description17 Call for an ambulance

Failure Mode Causes Effects Occ Det Sev RPN ActionsMultiple phone calls Calling different services 9 6 10 540

Delay Don't know the number Slow response time

6 9 10 540

Nurse doesn't communicateemergency

lack of knowledge Poor communication

2 6 10 120

Step Description18 Prepare documentation

Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay Unsure what to send

Busy with patient Copier malfunction Depends on the facility Burn discs

2 8 1 16

Step Description



19 Document on hospital to hospital intervention

Failure Mode Causes Effects Occ Det Sev RPN ActionsNot done Nurse doesn't know

Meditech down3 3 1 9

Calculated Totals

Total Risk Priority Number for the process 18839

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)

AnnotationChange: 10593

4th floor, chest pain

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