9/14/2015 InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=1309&ScenarioId=1726&Type=2 1/2

FailureModesandEffectsAnalysis(FMEA)Tool

TrackingLabs,OB/Gyn

UnitedStatesProfessional/MedicalSchool

Aim:Reduceriskofdelayedormissedtreatmentduetomissedlabreports

ProcessData

Date:05/02/2005

Step Description1 Labworkorderedinclinic

FailureMode Causes Effects Occ Det Sev RPN Actionslabmissed Norecord/promptofpending

labstreatmentdelay/poormaternalfetaloutcome

5 5 5 125 Keepcopyoflabrequest,reviewperiodically

Step Description2 Patientpresentstolab

FailureMode Causes Effects Occ Det Sev RPN ActionsNospecimencollected/notestsrun

Patientfailstogotolab missedproblem/treatmentdelaymostlikelydetectedafter4wks.

8 5 5 200

Step Description3 Labprocess(UMC,notTTUHSCprocess)

Step Description4 Labreportgenerated

FailureMode Causes Effects Occ Det Sev RPN Actionsmisplacedreport treatmentdelay 5 5 5 125

Step Description5 ClinicNApicksupreportsat7:30eachmorning

FailureMode Causes Effects Occ Det Sev RPN ActionsReportnotavailable Routedwronginlab treatmentdelay 1 5 5 25

Nolabpickup NAstaffhassickday,otherstaffmaynotbedesignated,mayforget

delayof1/2to1dayseeingreports

2 1 1 2 Backupstaffassigned

Reportspickedupincludereportstowrongphysician,wrongclinicsite

incorrectlylabeledlabrequests,labprocess

Addstostafftime,effortsortingclinicapplicablelabs

7 2 2 28

Step Description6 NAlooksforpatientID/MRinIDX

Step Description7 LabreportstampedforMDsignature

FailureMode Causes Effects Occ Det Sev RPN ActionsLabnotstamped nostampavailable/staff

unfamiliarwithprocessnopromptforMD/Providernotes

1 1 1 1 NotifyNurseManagerifnostampavailable

Step Description8 DivideintoOBandGYN

Step Description9 OB:obtaincliniccharts

FailureMode Causes Effects Occ Det Sev RPN ActionsChartnotavailable Chartmaybeinotherdept

clinicorinMD'sofficedelayuntilchartfound,applicableptinformationnotavailable

2 5 2 20

Step Description10 GYN:ordercentralMR

FailureMode Causes Effects Occ Det Sev RPN Actionsmissing/unavailablechart centralMRinuseinother

clinicpatientinformationnotavailableforfollowuporclinicaldecisionmaking

5 2 5 50

Step Description11 Attachlabreporttofrontofchart

Step Description12 PlacechartwithreportinMD/provider'sbox

9/14/2015 InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=1309&ScenarioId=1726&Type=2 2/2

FailureMode Causes Effects Occ Det Sev RPN Actionsphysicianoutornocleardesigneetoreview

notcommunicatedtoNAhandlinglabreports

delayedreview 5 2 2 20 Prioritizeabnormallabsandconsultscheduleforcoverage.

Step Description13 MD/Providerreviewslabreports

Step Description14 MD/Providerinitials/indicatestypeoffollowupneeded

FailureMode Causes Effects Occ Det Sev RPN ActionsMDfailstosign/initial,indicatefollowup

interruptionstoprocess noindicationofintendedtreatmentorinstructionsforfollowup

1 1 5 5 NursequestionsMDregardinginstructionsforfollowup

Step Description15 MDplacesinrespectivenurse'sbox

FailureMode Causes Effects Occ Det Sev RPN Actionsdelayedresponseobtainingchart

nurseoutsick,vacation,etc.

delayedpatientnotification/delayedtreatment

5 1 2 10 Teamworkhasbeenemphasizedtocoveralltasks

Step Description16 NursecallsorsendsletterasindicatedbyMD

FailureMode Causes Effects Occ Det Sev RPN Actionspatientnotnotifiedforfollowup

patienthasnophone,disconnectedphone,wrongaddress

patientnotcontacted/potentialtreatmentdelay

8 2 5 80 IfOBpatienthasSTD,healthdeptnotified,tracksdownpatientifpossible.

Step Description17 AttemptscallsX3,thenlettersent

CalculatedTotals

TotalRiskPriorityNumberfortheprocess 691

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

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

AnnotationNone