9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

UrgentMedOrdersNewAdmitsHospitalistOffSite
St.John'sRehabHospital
Toronto,Ontario,Ontario,Canada
Other

Aim:ReducetheRiskPriorityNumber(RPN)fortheurgentmedicationorderingprocessfornewadmissionsby30percentin6months.
ProcessData
Date:03/17/2006
Step

Description

RN/RPNadmittingpatientcompletesaninitialscreeningassessment
(vitalsetc.).

FailureMode

Causes

Effects

RN/RPNproceedswithfull
healthpatternsassessment
insteadofaquickscreening
assessment.

Clinicaljudgementof
RN/RPN.

Patient'surgentcareneeds
arenotprioritizedandnot
metinatimelymanner.

Competingworkload
demands.

Occ Det Sev RPN Actions

2

Lackofsupportfrom
colleagues.

AssignedRN/RPNisdelayed
inattendingtonewly
admittedpatient.

Systemicissues:
Competingpatientcare
demands.

36 Educationwithnursingstaff
aroundprioritizingcare(e.g.
rapidscreeningassessment
v.sfullheathpatterns
assessment).
Havea"rapidscreening
assessment"preceedthefull
healthpatternsassessment
inthehealthrecordbut
maintainitasone

Patientcareneedsarenot
metinatimelymanner.

Staffingshortages(realand/
orperceived)ontheunit.

14 Ensurethatmeasuresand
timeareinplacetoallow
nursingstafftoregularly
discusspatientassignment/
caseloadandstrategiesfor
meetingorprioritizing
patientcaredelivery.

Unableto,orhesitancywith,
discussingpatientcaseload
demandswithcolleagues
(teamrelationships/
dynamics).
Step

Description

RN/RPNreviewstransferofcarenotesfromreferringfacilityatpoint
ofpatientadmission.

FailureMode

Causes

Effects

Pertinentinformation
regardingpatient'shealth
statusnotavailablein
transferofcarenotesfrom
referringfacility.

SJRHdoesnotrequirethatall
referringfacilitiesusea
standardizedtransferofcare
package.

Delayedacesstopertinent
patientinformationtoassist
nursingstaffwithinitial
assessment.

Occ Det Sev RPN Actions

5

90 Establishanaudited
minimumstandardfor
patientinformation/transfer
ofcarenotesfornew
admissionsfromreferring
facilities.

Anothermemberofthe
interdisciplinaryteamis
reviewingtransfernotes
awayfromthenursing
station.RNunabletolocate
inatimelymanner.

Teamdependentonpaper
baseddocumentationfrom
referringfacilitythatdoesnot
permitsimultaneousaccess
topatientrecord.

Pertinentpatientinformation
notaccessibletoRNto
facilitatewith"rapid
screeningassessment"at
admission.

40 Limitaccesstohealthrecord
ofnewlyadmittedtonursing
stationuntil"rapidscreening
assessment"hasbeen
completedandsignedoff.

Incorrectpatientinformation
availabletonursingstaff.

Healthcarestaffbusyor
Pertinentpatientinformation
distractedatreferringfacility. notavailableatpointof
assessment.
Theremaybetwopatients
withthesameorsimilar
Incorrectpatientinformation
namebeingmovedwithinthe maybeusedtosupportinitial
facilityonthesameday.
assessmentbyRNandteam
unknowingly.
Ambulancewaitingand
transferofcarenotesnot
fullyassembledpriorto
patientdi

Teamhasnotbeengiventhe
opportunitytosetpriorities
regardingtimelyaccessto
patientinformationduringthe
admissio

Maketransparentthe
identityofthenurse
assignedtothenewly
admittedpatientforteam
membersthroughuseof

Step

Description

HospitalistnotonunitRNpageshim/heraspatientrequires
immediatemedorder(s).

FailureMode

Causes

Effects

Hospitalistdoesnotrespond
topagefromRNinatimely
manner.

Hospitalistmaybeotherwise
occupiedwithofforonsite
care/service.

Delayedcommunicationwith
Hospitalistregardingpatient
statusanddelayedmedical

10

60 Nursecompletesadouble
checkofpatientidentityas
partofthe"rapidscreening
assessment"process.

Occ Det Sev RPN Actions

2

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=2067&ScenarioId=2580&Type=1

14 ReferissuetotheMedical
AdvisoryCommitteeto
assesspossibilityof

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9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
Failureofpagingdevice.

careforpatient.

establishingaprocessfor
Hospitaliststodistinguish
betweenurgentandnon
urgentpages.
Educatenursingstaffre:
backupproceduresfor
failureofcalledphysicianto
respond.

HospitaistrespondstoRN's
pagebutindicatesthatthey
arecurrentlyunavailableto
addressquestions.

Hospitalistiscurrently
occupiedwithother
care/services.

Delayedcommunicationwith
Hospitalistregardingpatient
statusanddelayedmedical
careforpatient.

Step

Description

RNrelayspatientcondition/findingstoHospitalistoverphone(vitals,
transferinformation).

FailureMode

Causes

Discrepancybetween
informationrelayedbyRN
andreceivedbyHospitalist
overtelephone.

Telecommunicationbarriers. Incorrectmedicationorders
recordedbyRNonPOS.
Noisynursingstation.
Incorrectmedicationorders
StaffinterruptingRNand/or fromHospitalist.
Hospitalistwhileon
telephone.

Effects

10

Occ Det Sev RPN Actions

3

10

Description

HospitalistprovidesRNwithaverbalmed(s)orderovertelephone.

FailureMode

Causes

Effects

RNhearssomethingdifferent Noisynursingstation
Incorrectmed(s)order
thanwhatisintendedfor
environment.
recordedbyRNonPOS.
communicationoverthe
telephonebytheHospitalist. LanguagebarrierbetweenRN
andHospitalist.

60 Reinforcetheimportanceof
theRNlocatingaquietplace
(e.g.teamcoordinator's
office)forcommunicating
withHospitalistoverthe
telephone.
Exploreopportunitiesfor
givingstaffandpatientsa
visualcuethattheRNisnot
tobedisturbedduring

Languagebarriersbetween
RNandHospitalist.

Step

20 Ensurenursingstaffand
medicalstaffareawareof
backupproceduresfor
accessingahospitalistduring
regularbusinesshoursand
afterhours.

Occ Det Sev RPN Actions

3

10

60 Actionsasnotedinstep4.
Explorefutureopportunities
forcomputerizedonline
orderentry.

StaffinterruptingRNwhile
receivingmed(s)orderover
thetelephone.
Step

Description

VerbalordersfromHospitalistovertelephonearerecordedbyRN
manuallyonPOS.

FailureMode

Causes

Effects

Patientallergies/
contraindicationsnotknown/
recordedbyRNonPOSfor
immediateverbalmed(s)
order.

Informationmaynothave
beenavailabletoRNinthe
transferofcarenotes.

Potentialforpatienttohave
anadversedrugreaction.

Occ Det Sev RPN Actions

6

10

Med(s)orderedforwrong
patient.

Patientlanguagebarrier
knownallergiescannotbe
communicatedtoRN.

120 RNwillberequiredtoobtain
anddocumentpatient
allergies/contraindications
inthe"rapidscreening
assessment".

RNbusy/interruptedwith
urgentcareprocessand
missesrecordingofallergies
onPOS.
Verbalordersrecordedon
wrongchart(POS).

Multipleadmissionsand
incorrectpaperworkplaced
innewpatientchart.
Wrongchartselectedduring
med(s)order
documentation.

Potentialforpatienttohave
anadversedrugreaction.

Explorethepossibilityofan
independentdoublecheck
and/oraselfdoublecheck
processforhighalert
medications.

Environmentalnoise/work
interruptions.
Twopatientswithsimilar
names.
Step

Description

RNrepeatsverbalordersovertelephonetoHospitalist.

FailureMode

Causes

Effects

Occ Det Sev RPN Actions

Discrepancybetweenmed(s) Noisyenvironmentatnursing Potentialforincorrectmed(s)

orderrelayedandmed(s)
station.
orderreceivedand
orderreceivedbetweenRN
documentedonPOS.
andHospitalist.
LanguagebarrierbetweenRN
andHospitalist.

RNomitsstepdoesnot
repeatverbalordersover
telephonetoHospitalist.

Busy/noisyworking
environment.
Competingcareneeds/
workloaddemands.

45 Developaprocedurefor
managingpaperworkfor
patientswithsimilarnames
whoresideonthesame
patientcareunit.

Potentialforwrongmed
ordertoberecordedbyRN
onPOS.

4 Locateaquietlocationfor
RNtocommunicatewith
Hospitalistoverthe
telephone.
243 Educateallteammembers
abouttheimportanceof
repeatingbackmedorders
receivedbyaHospitalist
overthetelephone.

Physicianunwillingnessto
spendtimerepeatingverbal

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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
ordersovertelephone.

Step

Description

RNreturnsPOS/med(s)ordertohealthrecordforsigningby
Hospitalistwhennextonpatientunit.

FailureMode

Causes

Med(s)ordersonPhysician's Standardizedpracticefor
Ordersheetarenotalways
HospitalistsigningofPOSnot
placeddirectlyonchartto
inplaceacrossthehospital.
awaitsignatureofHospitalist.
SomepatientcareunitsPOS
sheetsonphysician
clipboardsasaflagfor
review/signingbyHospitalist
whennextin.

Effects
POSmisplaced.

Occ Det Sev RPN Actions

8

POSfiledinthewrongchart.
Patientdoesnotreceive
medsorreceivesthewrong
medication.

10

80 Standardizepracticefor
HospitalistsigniningofPOS
sheetsdirectlyinpatient
healthrecords/charts
acrossthehospital.All
information,ordersetc.must
bestoredinthepatient
healthrecordatalltimes.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

886

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

10=VerylikelyitWILLNOTbedetected

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

Annotation
None

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