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=7118&ScenarioId=8356&Type=1 1/1

Failure Modes and Effects Analysis (FMEA) Tool

Wrist­banding Process Improvement

United StatesHospital­Community

Aim: Reduction in patient identification related errors

Process Data

Date: 08/06/2008

Step Description1 Patient Arrives for Lab

Failure Mode Causes Effects Occ Det Sev RPN ActionsPatient does not arrive to lab Confused, Poor signage,

Language BarrierLab tests do not get done ornot done in a timely manner

3 1 6 18 Have centralized check in forall tests/procedures

Step Description2 Patient Checks in at Laboratory

Step Description3 Patient is called back by Lab Tech

Step Description4 Tech verbally identifies patient

Failure Mode Causes Effects Occ Det Sev RPN ActionsTech incorrectly identifies thepatient Tech doesn't identify thepatient at all

Lack of knowledge aboutidentifiers Non compliance

Incorrect tests 2 8 9 144 Wristbanding at a centralcheck in location; patient toverify information is correcton the wristband beforeleaving admissions.

Step Description5 Test completed

Step Description6 Patient Leaves

Calculated Totals

Total Risk Priority Number for the process 162

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)

AnnotationNone