9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

AlarmManagement
ColiseumNorthsideHosptial
Macon,Georgia,UnitedStates
HospitalCommunity

Aim:ReducenoncriticalalarmsintheICUby10%
ProcessData
Date:04/21/2015
Step

Description

PatientplacedonTelemetry

FailureMode

Causes

Effects

ICUistrackingthewrong
patient

ICUhasnotconfirmedwith
thefloornursethepatient
identificationandtelemetry
boxnumber.

Thewrongpatientisbeing
monitored.Therightcare
doesnotgetdeliveredtothe
rightpatient.

FailureMode

Causes

Effects

Knownpatientconditionis
notappropriately
communicated.

Patient'snormalconditionis
viewedasanactionable
alarm.

Patientsthathavetremors
mayactivatealarmfor
"cannotanalyze"ECG.

Step

Description

Patientisactiveinbed

Step

Description

Patientleadscomeloose

FailureMode

Causes

Effects

Patientcannotbeproperly
monitored.

Electrodesarenotapplied
properlytoensure
connectivity.

Alarmsaresounded
unnecessarily.Staff'stimeis
takenawayfromotherduties
toattendtoalooselead.

Step

Description

PatientisoffTelemetryforinterventionsICUnotnotified

FailureMode

Causes

Effects

Patientisnotproperly
monitored.

Patientsaretakenoffof
telemetryforvariousreasons
i.e.baths,PT,radiology
studies,proceduresand
communicationbetweenthe
floorandICUisnottimely.

Patientcouldhaveanegative
outcomethatgoes
undetectedanddelay
intervention.Alarmsare
activatedunnecessarily.Staff
isinterruptedperforming
otherdutiestocheckonthe
patient.

Step

Description

PatientreturnsfrominterventionsICUnotnotified

FailureMode

Causes

Effects

Patientimproperly
monitored.

Staffdoesnotcommunicate
inatimelyfashionwiththe
ICUmonitortechwhenthe
patienthasreturnedandit
beingplacedbackon
telemetry.

Negativepatientoutcome.
Unnecessaryalarms.
Unnecessaryeffortslocating
thepatient.

Step

Description

Alarmsparametersaresettoonarrowforpatient'snormalcondition

FailureMode

Causes

Effects

Alarmsarenotadjustedby
nursingstafftoreflectan
actionableparameter.

Monitoringequipmentreturns
todefaultparameterswith
eachnewpatient.Thenurses
donothaveguidanceasto
whatparametersmaybeset
to.

Allalarmsareactivated
creatinganabundanceof
alarmsthatcouldleadto
fatigue.

Step

Description

TelemetryBoxbatteryislow

Occ Det Sev RPN Actions

2

10

40 Verificationprocesswhen
placingapatienton
telemetryinitiallyor
subsequentlyshouldbedone
bytheICUnurseandthe
personsplacingthepatient
ontelemetry.Thisincludes
thepatient'sname,DOBand
telemetryboxnumberwith
verificationfromICUof
capture.

Occ Det Sev RPN Actions

3

12 NotifyICUstaffofpatient
inherentcondition.Consider
delayinalarm.

Occ Det Sev RPN Actions

5

10

100 Prepareskinbeforeapplying
ECGelectrodes.Routinely
replaceECGelectrodes
every24hourstoprevent
themfromdryingout.

Occ Det Sev RPN Actions

8

10

400 Staffeducatedonthe
importanceoftimely
notificationtotheICU
monitortechthatthepatient
isbeingtakenofftelemetry
andthereasonwhy.

Occ Det Sev RPN Actions

7

105 Educatestaffonthe
importanceoftimely
communicationwhenplacing
apatientbackontelemetry.

Occ Det Sev RPN Actions

10

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19700&ScenarioId=21645&Type=1

100 Draftpolicythatwillprovide
guidancetostaffforthe
determinationofacceptable
parameters.Considerdelays
forcertainalarmssuchas
SpO2alarms(15sec)

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9/14/2015
FailureMode

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
Causes

Batteriesarenotchangedon Policyhasnotbeen
aroutinebasis.
establishedastohowoften
tochangethebatteries.

Effects
Patientscouldbeimproperly
monitored,alarmsactivated
unnecessarily,staff
interruptedfromotherduties
forbatterychanges.

Occ Det Sev RPN Actions

5

25 Establisharoutinefor
batteryreplacementand
educatestaffonthenewly
establishedroutine.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

782

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

10=VerylikelyitWILLNOTbedetected

Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)

Annotation
None

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19700&ScenarioId=21645&Type=1

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