FMEA Forms

FAILURE MODE EFEECTS ANALYSIS
PROCESS STEPS: Describe the process graphically, according to your policy and procedure for the activity, and number each one. If the process is complex you may want to select one process step or sub-process to work on. DIRECT ADMITS
1 MD Decision to Admit 2 Obtain Orders 3 Bed Assignment 4 Registration 5 Transport or Direction To Unit
List the sub-processes for each process step and letter

Sub process steps A. MD/Office staff call hospital - why? B. Verification of bed availability with? C. D. E. F. Sub process steps A. Phone B. Fax C. Send with patient D. E. F. Sub process steps A. Determine bed type B. Check Bed Availability C. Notify unit of bed assignment D. E. F. Sub process steps A. Enter Data B. Verify Accuracy of data in system C. Complete Advance Directives/Rights/HIPPA D. E. F. Sub process steps A. Call transport or direct patient to area B. Call unit to come and get patient C. Transport pt to appropriate care area D. E. F.
FAILURE MODE EFFECTS ANALYSIS SUB-PROCESS STEPS: Graphically describe the sub-processes for each process step and then list the possible failure modes for each one If the process is complex you may want to select sub-process to work on. PROCESS: MD DECISION TO ADMIT A MD/Office Staff calls Hospital B Verification of Bed Availability C D E
Failure Modes 1. Wrong person contacted with info 2. Patient arrives without prior notice 3 4 5 6
Failure Modes 1. No bed available 2 3 4 5 6
Failure Modes 1 2 3 4 5 6
FAILURE MODE EFFECTS ANALYSIS SUB-PROCESS STEPS: Graphically describe the sub-processes for each process step and then list the possible failure modes for each one If the process is complex you may want to select sub-process to work on. PROCESS: OBTAIN ORDERS A MD/Office Staff phones/faxes/ gives orders to patient B C D E
Failure Modes 1 No orders received 2 Orders incomplete or illegible 3 4 5 6
FAILURE MODE EFFECTS ANALYSIS SUB-PROCESS STEPS: Graphically describe the sub-processes for each proces step and then list the possible failure modes for each one If the process is complex you may want to select sub-process to work on. PROCESS: BED ASSIGNMENT A Determine Bed Type B Check Bed Availability C Assign Bed D E
Failure Modes 1 Incorrect assignment made (gender, age, dx) 2 3 4 5 6
Failure Modes 1 No bed available (high census, type, etc.) 2 Overlapping bed assignment 3 Bed not clean/bed broken 4 Late discharges 5 6
Failure Modes 1 Bed assignment person not available 2 No bed assignment made 3 Patient arrives to floor without bed assigned 4 5 6
FAILURE MODE EFFECTS ANALYSIS SUB-PROCESS STEPS: Graphically describe the sub-processes for each proces step and then list the possible failure modes for each one If the process is complex you may want to select sub-process to work on. PROCESS: REGISTRATION A Register Patient B Enter Data Verify Accuracy of Data already in
system
C Advance Directives Consents/HIPAA
D Patient ID
E Documents to Care Area
Failure Modes 1 Clerk not available 2 Patient reports to wrong area 3 4 5 6
Failure Modes 1 System down 2 Incorrect info entered 3 Patient unable to give or verify accuracy 4 5 6
Failure Modes 1 Patient incorrectly identified (banded) 2 Patient not "banded" 3 4 5 6
Failure Modes 1 Documents not available to caregivers 2 3 4 5 6
FAILURE MODE EFFECTS ANALYSIS SUB-PROCESS STEPS: Graphically describe the sub-processes for each proces step and then list the possible failure modes for each one If the process is complex you may want to select sub-process to work on. PROCESS: TRANSPORT A Call Transport B Direct Patient to Care Area C Call unit to come & get patient D Transport to Unit E
Failure Modes 1 Transport not available 2 Transport equipment not available 3 4 5 6
Failure Modes 1 Patient gets lost 2 No one available to receive patient 3 4 5 6
Failure Modes 1 Staff not available to get patient 2 3 4 5 6
Failure Modes 1 Patient arrives without being registered 2 Patient arrives without unit notification 3 Patient arrives and bed not ready 4 5 6
HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

Process Step: MD Decision to Admit Potential Failure Mode (what could go wrong) Effect (what could happen) 1. Wrong person contacted with information Delay in care Customer dissatisfaction Increased risk of bad outcomes Delay in treatment Treatment errors Customer dissatisfaction Staff overburdened Delay in treatment Customer dissatisfaction Patient Safety/Risk Issue Increased risk of noso. infections (rush to clean) Patient in inappropriate level of care Severity: 1 = no harm; 2 = temporary harm; 3 = permanent harm; 4 = Death/Major loss of function Potential Cause(s) (why the failure could occur - list all possibilities for each failure mode and conduct analysis for all failure modes within the scope of this FMEA) Probability: 1 = remote; 2 = uncommon; 3 = occasional; 4 = frequent Current Control Measure 1. Unclear hospital process 2. Noncompliant MD's 3. Lack of Education regarding process 1. MD/Office staff too busy to call or forgets 2. Unclear hospital process 3. Noncompliant MD/Office staff 1. High census 2. Delay in cleaning 3. Discharge delays 4. Inapproriate utilization 5. Communication 2. Patient arrives without prior notice 3. No bed available
Increased risk of bad outcomes Loss of revenue
Detectability: 1 = Very Likely; 2 = Likely; 3 = UnLikely; 4 = Very Unlikely Hazard Score (RPN = Severity x Probability x Detectablility) Decision: Proceed or Rationale for Stopping based on score or explanation Action (Eliminate, Control or Accept) Description of Intervention
Outcome Measure
Person Responsible Management Concurrence (Yes or No) Implementation Time Frame/Date Due

Process Step: Obtain Orders Potential Failure Mode (what could go wrong) Effect (what could happen) 1. No orders received Delay in treatment Incorrect treatment Increased risk of bad outcomes Customer Dissatisfaction Increased LOS Increased work load for staff Severity: 1 = no harm; 2 = temporary harm; 3 = permanent harm; 4 = Death/Major loss of function Potential Cause(s) (why the failure could occur - list all possibilities for each failure mode and conduct analysis for all failure modes within the scope of this FMEA) MD too busy MD noncompliance Patient loses them Fax busy/malfunction Admit status not documented or documented incorrectly Fax copies unreadable Handwriting illegible Lack of education (what's required by Reg. Agencies) Probability: 1 = remote; 2 = uncommon; 3 = occasional; 4 = frequent Current Control Measure 2. Orders incomplete or illegible Delay in treatment Incorrect treatment
page 2
Outcome Measure

Process Step: Bed Assignment Potential Failure Mode (what could go wrong) 1. Incorrect assignment made (gender, age, diagnosis, etc.) 2. No bed available (high census, type, etc) (See MD Decision to Admit Process) Effect (what could happen) Customer dissatisfaction Spread of infection Delay in treatment Severity: 1 = no harm; 2 = temporary harm; 3 = permanent harm; 4 = Death/Major loss of function Potential Cause(s) (why the failure could occur - list all possibilities for each failure mode and conduct analysis for all failure modes within the scope of this FMEA) Manual/decentralized process Inaccurate info Communication failure
page 3
3. Overlapping bed assignment
Customer dissatisfaction Delay in treatment
Manual/decentralized process Multiple contacts Inaccurate recordkeeping by units Communication failure
Probability: 1 = remote; 2 = uncommon; 3 = occasional; 4 = frequent Current Control Measure
Outcome Measure

Process Step: Bed Assignment Potential Failure Mode (what could go wrong) 4. Bed not clean/bed broken 5. Late Discharges
page 4
6. Bed assignment person not available
Effect (what could happen)
Increased risk of infection Incresed risk of injury Customer dissatisfaction
Hospital on diversion due to no beds Loss of revenue
Customer dissatisfaction Delay in treatment
Severity: 1 = no harm; 2 = temporary harm; 3 = permanent harm; 4 = Death/Major loss of function Potential Cause(s) (why the failure could occur - list all possibilities for each failure mode and conduct analysis for all failure modes within the scope of this FMEA) Probability: 1 = remote; 2 = uncommon; 3 = occasional; 4 = frequent Current Control Measure Unit not communicated with Env. Services that patient discharged Late rounding by MD's Awaiting diagnostic reports No back-up system in place
Outcome Measure

Process Step: Bed Assignment Potential Failure Mode (what could go wrong) 7. No bed assignment made 8. Patient arrives to floor without bed assigned
page 5
Delay in treatment Customer dissatisfaction
Delay in treatment Customer dissatisfaction
Severity: 1 = no harm; 2 = temporary harm; 3 = permanent harm; 4 = Death/Major loss of function Potential Cause(s) (why the failure could occur - list all possibilities for each failure mode and conduct analysis for all failure modes within the scope of this FMEA) Probability: 1 = remote; 2 = uncommon; 3 = occasional; 4 = frequent Current Control Measure Bed unavailable Not staff priority Lack of staff accountability/responsibility No request received Communication Failure
Outcome Measure

Process Step: Registration Potential Failure Mode (what could go wrong) 1. Registration Clerk not available 2. Patient reports to wrong area
page 6
3. System down
Severity: 1 = no harm; 2 = temporary harm; 3 = permanent harm; 4 = Death/Major loss of function Potential Cause(s) (why the failure could occur - list all possibilities for each failure mode and conduct analysis for all failure modes within the scope of this FMEA) Probability: 1 = remote; 2 = uncommon; 3 = occasional; 4 = frequent Current Control Measure
Outcome Measure

Process Step: Registration Potential Failure Mode (what could go wrong) 4. Incorrect info entered 5. Patient unable to give or verify accuracy of info
page 7
6. Patient incorrectly identified "banded"
Outcome Measure

Process Step: Registration Potential Failure Mode (what could go wrong) 7. Patient not "banded" identified 8. Documents not available to staff (i.e., consent to treat, etc.)
page 8
Outcome Measure

Process Step: Transport Potential Failure Mode (what could go wrong) 1. Transport not available 2. Appropriate transport equipment not available
page 9
3. Patient gets lost
Outcome Measure

Process Step: Transport Potential Failure Mode (what could go wrong) 4. No one available to receive patient 5. Staff not available to come and get patient
page 10
6. Patient arrives without being registered
Outcome Measure

Process Step: Transport Potential Failure Mode (what could go wrong) 7. Patient arrives without unit being notified 8. Patient arrives and bed not ready
page 11
Outcome Measure

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FAILURE MODE EFEECTS ANALYSIS

List the sub-processes for each process step and letter

Failure Modes 1. No bed available 2 3 4 5 6

Failure Modes 1 No orders received 2 Orders incomplete or illegible 3 4 5 6

Failure Modes 1 Incorrect assignment made (gender, age, dx) 2 3 4 5 6

C Advance Directives Consents/HIPAA

E Documents to Care Area

Failure Modes 1 Clerk not available 2 Patient reports to wrong area 3 4 5 6

Failure Modes 1 Patient incorrectly identified (banded) 2 Patient not "banded" 3 4 5 6

Failure Modes 1 Documents not available to caregivers 2 3 4 5 6

Failure Modes 1 Transport not available 2 Transport equipment not available 3 4 5 6

Failure Modes 1 Patient gets lost 2 No one available to receive patient 3 4 5 6

Failure Modes 1 Staff not available to get patient 2 3 4 5 6

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

Increased risk of bad outcomes Loss of revenue

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

3. Overlapping bed assignment

Customer dissatisfaction Delay in treatment

Manual/decentralized process Multiple contacts Inaccurate recordkeeping by units Communication failure

Probability: 1 = remote; 2 = uncommon; 3 = occasional; 4 = frequent Current Control Measure

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

6. Bed assignment person not available

Effect (what could happen)

Increased risk of infection Incresed risk of injury Customer dissatisfaction

Hospital on diversion due to no beds Loss of revenue

Customer dissatisfaction Delay in treatment

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

Effect (what could happen)

Delay in treatment Customer dissatisfaction

Delay in treatment Customer dissatisfaction

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

Effect (what could happen)

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

6. Patient incorrectly identified "banded"

Effect (what could happen)

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

Effect (what could happen)

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

3. Patient gets lost

Effect (what could happen)

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

6. Patient arrives without being registered

Effect (what could happen)

HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

Effect (what could happen)

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