9/14/2015 InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=1958&ScenarioId=2461&Type=1 1/2

FailureModesandEffectsAnalysis(FMEA)Tool

AMICare:DoortoBalloonin120Minutes

MethodistHospitalNorthMemphis,Tennessee,UnitedStatesHospitalCommunity

Aim:IncaringforemergentAMIpatients,by12/15/05removeallbarrierstoachievingreperfusionwithin120minutesfromarrivaltohospitalatleast95%ofthetime.

ProcessData

Date:12/04/2005

Step Description1 PatientprocessedthroughRapidTriage

FailureMode Causes Effects Occ Det Sev RPN ActionsDelayinrapidtriage BackupinED

InsufficientstaffingUrgencyofcasenotidentified

DelayininitiationofChestPainTrackI

1 2 5 10 EnsureadequatestaffingandpropertrainingtoensurethatpotentialAMIpatientsarerecognizedandtheteamknowswhatstepstotake.

Delayintreatmentwitharrivalbyambulance

CommunicationbetweenEMTandED

Delayintreatment 5 4 5 100 ImprovecommunicationsbetweenEDandEMT

Step Description2 12LeadEKGdonewithin2minutesandgiventoEDMD

FailureMode Causes Effects Occ Det Sev RPN Actions12LeadEKGnotdone Equipmentnotinareano

oneavailabletoperformtestequipmentnotworking.

Delayindiagnosisdelayintreatment

1 1 6 6 Ensureequipmentinworkingorderwithtrainedstaffplaceforrapidaccessibility.

PendingEMTarrivaltoreviewremoteEKG

Nowaytotransmitfromambulance

Delayindiagnosis 8 4 8 256 LifeNetsystemtoallowtransmissionfromEMTtoED

Step Description3 ChestPainTrackIfullyinitiatedwithin10minutes

FailureMode Causes Effects Occ Det Sev RPN ActionsChestPainTrackInotinitiated

StaffnottrainedtoinitiatenocopieshandycasenotrecognizedaspotentialAMInurseremiss.

Treatmentdelayedwithpotentialharmtopatien

1 1 8 8 Propertrainingandresourcesfollowuponanymissedopportunities.

ChestPainTrackIinitiatedincorrectly

Impropertrainingorexperience

Delayininitiatingtreatment 1 2 6 12 Ensurealltriagenursesareproperlytrained.

Notallmedicationsnotreadilyavailable

Stocknotreplenished Delayintreatment 4 7 5 140 ProvideAMIMedicationKittoensureallnecessarydrugsandtesttubeswithineasyonetouchaccess.

Delayinassemblinglabtubesandorders

Logisticsofgatheringsupplies

Delays 7 2 5 70 HaveallsuppliesinAMIKit

Step Description4 CompareEKGtoanypreviousstudiesonfile

FailureMode Causes Effects Occ Det Sev RPN Actionsdelayinpullingpreviousstudies

MUSEinanotherareaofED Delayindiagnosis 5 1 3 15 RelocatedMUSEtorapidtriagearea

Step Description5 DiagnosisofAMImade

FailureMode Causes Effects Occ Det Sev RPN ActionsDiagnosisofAMInotmadeimmediately

Physicianerrorunavailabilityofalltestresultstoverifyatypicalpresentingsymptoms

Delayintreatmentpotentiallyfatalerror

2 4 10 80 EnsurerapiddiagnosticinputassessanyfailuresBIoNetpointofcaretestingsystemtospeedlabresults

Step Description6 CathTeam&Cardiologistallsummonedatonce

FailureMode Causes Effects Occ Det Sev RPN ActionsToomuchtimespentoncoordinatingCathTeamandCardiologist

Logisticsof4phonecallsawaiting4responses

Delayingettingcathstarted 8 4 3 96 Batchpagerandcascadecommunicationstoacknowledgewhenenroute.RemoveHouseSupervisorfromcommunicationloop

Cardiologistdoesn'trealizeurgencyofneed

Communicationweaknessunclearexpectations

Delayinprocedureandpotentialincreaseincardiacdamage

8 6 9 432 CodeSTEMIScriptingandcommunicationfeedback

9/14/2015 InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=1958&ScenarioId=2461&Type=1 2/2

Step Description7 Cathteam/cardiologistreadyforcase

FailureMode Causes Effects Occ Det Sev RPN ActionsDelayintraffictraveltimefromcartoCathLab

TrafficproblemsphysicianandAssociateparkingonothersideofhospitalnoconvenientspotsclosetoentrance

Delayintreatment 10 2 3 60 LiftanyparkingrestrictionsforCathTeam/Cardiologist

Step Description8 PatienttransferredfromEDwithin30minutesofarrival

FailureMode Causes Effects Occ Det Sev RPN ActionsPatientnottransferredwithin30minutes

DelayinCathTeamarrivaldelayinPCIMDarrivalcathlabnotreadynooneavailabletoassistEDRNintransport

Delayinprocedure 8 4 4 128 Processchangetohave2preparelabwhile3rdgoestoassistwithpatienttransport

Step Description9 Balloonsuccessfullyinsertedwithin120minutes

FailureMode Causes Effects Occ Det Sev RPN ActionsBalloonnotinsertedwithin120minutes

Latearrivaltocathlabproblemswithpatientreperfusion

Increasedriskofcardiacdamage

8 4 10 320 Removeallcontrollablebarriersandprovidefeedbackofperformance

CalculatedTotals

TotalRiskPriorityNumberfortheprocess 1733

Occ: LikelihoodofOccurrence(110)Det: LikelihoodofDetection(110) NOTE: 1=VerylikelyitWILLbedetected

10=VerylikelyitWILLNOTbedetectedSev:Severity(110)RPN:RiskPriorityNumber(OccDetSev)

AnnotationNone