9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofCopyofCopyofTBQuestionnaireAllClini
CommunityHealthCenterofLubbock
Lubbock,Texas,UnitedStates
PrimaryCarePractice

Aim:ToreducetheRiskPriorityNumberRPNfortheAdministrationoftheTuberculosisQuestionnaire
ProcessData
Date:10/30/2006
Step

Description

PatientgivenTBquestionnaireatsignin

FailureMode

Causes

Stepmissed.Patientnotable Staffnottrainedto
toread.
administerquestionnaire.
Languagebarrier.Illiteracy
Step

Description

TBquestionnairefilledout

Effects
Potentialtubercuosisinfection
missedandothersputatrisk

FailureMode

Causes

Formfilledoutinnaccurately
bypatient

Patientnotabetounderstand Innacurateinformation.
questions
Necessaryprecautions
missed.

Effects

Step

Description

Changequestionnaire,toomanyfalsepositives(patientsanswwering
yestoallquestions

FailureMode

Causes

Effects

Toomanypatientswere
answeringyestoallthe
questions

Questionsnotclear

Toomuchnurses'timespent
onfalsepositives

Step

Description

PSRlooksatquestionnaire

FailureMode

Causes

Effects

Misinterpretation
Innacuratedata

Lackoftraining
Patientembarrassment
Languagebarriers/Illiteracy

Riskofinfection

Step

Description

Notifynurseofpositiveresponse(s)

FailureMode

Causes

Failuretonotifynurse

Inadequateassessmentinfo RiskofspreadofTB
Haste

Step

Description

Patientbroughttoexamroom.

Effects

FailureMode

Causes

Effects

Nonurseavailable.
Noroomavailable

Notapriority.

Spreadofinfection

Step

Description

ProvidepatientwithPPE(tissue,surgicalmask)

FailureMode

Causes

Effects

NoPPEavailable
Uncooperativepatient

Failuretoordersupplies
Toosicktowearmask
Inadequateinstructionsto
thepatient

Riskspreadofinfection

FailureMode

Causes

Effects

PPEnotavailable.
ImproperuseofPPE.

Inadaquateordering.
LackoftrainingonPPEuse.

Increaseriskofstaff
infection.

Step

Description

NursedonsPPE.

Step

Description

Initialassessmentcompletedbynurse.

FailureMode

Causes

Effects

Initialassessmentnot
completed.

Interruptions.

Otherhealthprofessionals
enterroomunawareofrisk

Occ Det Sev RPN Actions

5

50 Providestafftraining.
Providebilingual
questionnaire.

Occ Det Sev RPN Actions

5

70 Providethorough
instructions.Providebilingual
questionnaires.

Occ Det Sev RPN Actions

10

10

10 1000 Changedthequestionnaire

Occ Det Sev RPN Actions

5

320 TrainingofPSRs

Occ Det Sev RPN Actions

2

128 TrainPSRtonotifynursefor
eachpositiveresponse.

Occ Det Sev RPN Actions

8

576 Conveyimportanceof
followingprocedure.

Occ Det Sev RPN Actions

3

216 Revamporderingprocessto
assuresupplyavailabiltity.
Provideadequate
instructionstothepatient.

Occ Det Sev RPN Actions

2

144 InsurePPEavailability.
Propertrainingonuseof
PPE.

Occ Det Sev RPN Actions

2

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=3986&ScenarioId=4818&Type=1

128 Minimizeinterruptions:Post
sign"ICEvaluationin

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
ofTBexposure.

Step

Description

10

Providerentersexamroom.

FailureMode

Causes

Effects

ProviderenterswithoutPPE.

Signnotposted.
Lackoftraining.
PPEnotavailable.

RiskofspreadofTB.

Step

Description

11

Evaluatepatientandarrangeforproperdisposition.

FailureMode

Causes

Effects

Providerreceives
incomplete/inaccurateinfo.

Nurseinterruptedinprocess
ofevaluatingpatient.

Increaseriskofinfection.

Progress"

Occ Det Sev RPN Actions

6

432 Havesignavailable.
Trainonappropriateuseof
signageinfo.
MakePPEeasilyaccessible,
byhavingdesgnated
location.

Occ Det Sev RPN Actions

5

320 Minimizepossibilityof
interruptionsbytrainingof
process.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

3384

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=3986&ScenarioId=4818&Type=1

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