ach fmeca hospital 2008
DESCRIPTION
gTRANSCRIPT
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=6921&ScenarioId=8141&Type=1 1/2
Failure Modes and Effects Analysis (FMEA) Tool
ACH FMECA Hospital 2008
Allen County HospitalIola, Kansas, United StatesHospitalCommunity
Aim: Reduce the Risk Priority Number (RPN) for the Code Blue Process in the mobile MRI/Nuclear Med trucks by 75% in 6 months.
Process Data
Date: 07/03/2008
Step Description1 Identification that patient has a problem
Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay in identification thatthere is a decline in status
No baseline O2 sat or VSobtained
Delay in treatment 4 1 8 32 Investigate obtaining O2 Satmonitor and Datascope forroutine baseline assessmenton mod to high risk patients Update basic assessmenttools obtained
Step Description2 Stop treatment
Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay in stopping procedurebased on physicalappearance and patientcomplaint only and lack ofBLS experience
Patients are hard to assessfrom the techs point of view patient can only voice issues.Techs may not have handson experience about BLSother than every 2 yeartraining.
Delay in assessment andtreatment
4 1 8 32 Improve on step 1 ofbaseline assessment notes: Clarification andeducation provided
Step Description3 911 is called rather than inhouse emergency number
Failure Mode Causes Effects Occ Det Sev RPN ActionsTech is not aware of calling"3000" for emergency helpwithin the facility
Lack of training ~ new techs techs go to differentfacilities with different rules
Delay in treatment 3 3 5 45 Involve staff in FMEAprocess beforepolicy/procedure devolpment* staff education and policyclarification with specificinformation on the code blueprocedure
Step Description4 Staff unaware there is an emergency
Failure Mode Causes Effects Occ Det Sev RPN ActionsDelay in treatment Tech calls 911 EMS
summoned hospital staffunware to respond
Delay in treatment 3 3 5 45 Written process/policy needscreated and shared
Step Description5 Staff respond
Failure Mode Causes Effects Occ Det Sev RPN ActionsStaff unaware of what tobring with them when theyrespond outside of thefacility.
Staff unaware of theirresponsibilities to bringtransportation cart to takepatient to the ED.
Delay in treatment of patient. 5 3 5 75 Education and writtenprocess
Step Description6 Patient taken to the ED for treatment
Failure Mode Causes Effects Occ Det Sev RPN ActionsLocation of mobile units have to wheel the patient allthe way around the buildingto get to the ED delay inadvance treatment.
Mobile units out of physicalhospital building
Potential lack of equipmentand procedure
8 1 10 80 Education and writtenprocess shared with hospitalstaff and mobile unit staff
Calculated Totals
Total Risk Priority Number for the process 309
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)
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=6921&ScenarioId=8141&Type=1 2/2
RPN: Risk Priority Number (Occ × Det × Sev)
AnnotationNone