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=19031&ScenarioId=21245&Type=2 1/2

Failure Modes and Effects Analysis (FMEA) Tool

Upgraded Cath Lab

Stringfellow Memorial HospitalAnniston, Alabama, United StatesHospital­Community

Aim: Open upgraded Cath Lab

Process Data

Date: 02/23/2015

Step Description1 Supply Storage ­ reduced space

Failure Mode Causes Effects Occ Det Sev RPN ActionsUnable to find critical suppliesduring procedure

Reduced Space Delayed Procedure 10 1 10 100 Look for storage space inother areas. Per Ken ­storage areas must bemonitored for temp andhumidity. Know whichsupplies don't need to havetemp/hum control.

Step Description2 Power Source ­ May not be able to use plugs for all equipment

Failure Mode Causes Effects Occ Det Sev RPN ActionsMay not be able to use plugsfor all equipment

Not enough 'red' plugs.Would overload certain plugs.

Delay in procedure 5 7 8 280 Test prior to opening.

Step Description3 Medical Air Supply Box ­ Location is unsafe

Failure Mode Causes Effects Occ Det Sev RPN ActionsTrip hazard. Box not moved with

renovation.Interruption of oxygen &suction.

10 10 8 800 Discuss with Plant Ops tohave it relocated. Orredesign box. Per Ken ­ wantto get the table in first andthen see if location/designneeds to be changed.

Step Description4 New documentation system

Failure Mode Causes Effects Occ Det Sev RPN ActionsStaff unable to use newsystem or slow. Unable toaccess info from previoussystem.

Unfamiliar with system. Inaccurate documentation.Physicians upset with delay.

10 10 2 200 Keep a 'host' computer willpt information from previoussystem. Inaccuratedocumentation can beamended.

Step Description5 Equipment Failure

Failure Mode Causes Effects Occ Det Sev RPN ActionsEquipment Failure New and untested; Staff

unfamiliar with equipmentUnable to completeprocedure

5 1 10 50 Test equipment beforeprocedures. Staff Educationabout how to troubleshootthe equipment.

Step Description6 Capnography

Failure Mode Causes Effects Occ Det Sev RPN ActionsNew equipment for Cath Lab­ staff not familiar and maynot use it properly. It is aregulatory requirement. Mayneed special equipment orcode so not may available.

New equipment. Equipment not used. 10 10 2 200 Mgr to review requirements.Staff training before move torenovated Cath Lab.

Nasal cannula is differentthan what is currently used.

Unable to use capnograpy. 5 10 5 250 We have 10 in stock.Carefusion rep should supplymore as needed.

Step Description7 Temperature & Humidity

Failure Mode Causes Effects Occ Det Sev RPN ActionsEquipment increases temp.Increased humidity.

Equipment Equipment might overheat ­could shut down Cath Lab.Humidity might increase riskof infection.

10 10 8 800 Discuss with Plant OpsDirector to see if design hasbeen changed. ­ Per Ken,Mechanical Room size

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=19031&ScenarioId=21245&Type=2 2/2

increased and can take anhigher heat load. Will needto be tested and adjustedafter completion ofrenovation.

Step Description8 Scrub Sink

Failure Mode Causes Effects Occ Det Sev RPN ActionsLimited space makes properscrubbing difficult.

Design ­ space issue. Improper scrubbing ­increased infection risk.Physician dissatisfaction.

5 10 7 350 Redesign. New Sink. PerKen, sink will be in samelocation but will be larger.

Water temp not hot enough Design. Physician dissatisfaction.Increased risk of infection.

10 10 5 500 Discuss with Plant Ops.Redesign. Per Ken ­ new hotwater tank being installed.

Step Description9 Positive Air Pressure

Failure Mode Causes Effects Occ Det Sev RPN ActionsNot enough pressure Design Increased infection risk 5 10 5 250 Talk with Plant Ops

Step Description10 Length of time it takes to move

Failure Mode Causes Effects Occ Det Sev RPN ActionsNeed to have at least 12hours with no procedures.

Emergency at other facility. Need to do all caths here. 3 10 7 210 First, move enough suppliesfor an emergency cath. Planto have no activity for atleast 12 hours ­ notify ERand cardiologists.

Step Description11 Work Space

Failure Mode Causes Effects Occ Det Sev RPN ActionsSize of work space slightlydecrease

Design of room 10 10 5 500 Organization ­ addedcabinets. Move someequipment ­ i.e. balloonpump.

Step Description12 Installation of unneeded equipment

Step Description13 Door on right (going in) warped ­ too much space at bottom

Failure Mode Causes Effects Occ Det Sev RPN ActionsToo much space at bottom Door warped Affect positive pressure

environment10 1 7 70 Repair or replace door

Step Description14 IVUS not operable

Failure Mode Causes Effects Occ Det Sev RPN ActionsEquipment not available Wires cut during construction Unable to perform ultrasound

of coronary arteries.5 10 5 250 Try to have IVUS repaired

before move. If that isn'tpossible inform cardiologiststhat it isn't available.

Calculated Totals

Total Risk Priority Number for the process 4810

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)

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