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FailureModesandEffectsAnalysis(FMEA)Tool

SurgicalFiresintheOR
MercyNorthAmbulatorySurgery
Ankeny,Iowa,UnitedStates
Other

Aim:ReducetheRPNnumberforFireSafetyintheOR(preventionandresponse)by50%
ProcessData
Date:02/18/2008
Step

Description

AvailabilityofSalineSolution

FailureMode

Causes

Salinenotonthefield
forgotten
salinenotreadilyavailablein spilled
theORsuite
used

Step

Description

HumidityControltocontrolstaticelectricity

FailureMode

Causes

Relativehumiditybelow30% Mechanicalfailue
intheORsuite
fluctuationofoutsideair
temp

Step

Description

Availabilityofextinguishers

Effects
Delayinextinguishingfire
Patientorstaffburned
Firewouldspreadquickly

Effects
Airbecomesdrywithgreater
potentialtoconductstatic
electricity...potentialsource
asanignitionpoint(spark)in
thefiretriangel.

FailureMode

Causes

Effects

Missing
Empty
Lackofknowledgebystaff
oncorrectoperationof
extinguisher,Malfunctionof
equipment,attemptto
extinguishtoodistantfrom
fire

Lackoforientation,training
Ineffectivelocationof
extinguisherstoOR

Firespreads
Patient/Staffinjured
Evacuationofentire
department
Surgeriesaborted

Step

Description

tentingduringanesthesia

FailureMode

Causes

Effects

Oxygenadministration
interfereswiththesurgical
field

surgeon/anesthesiarequest
useofO2duringprocedure

BuildupofO2,CO2
Increasethecombustability
ofafirethatwasstartedby
anothersource

Step

Description

barrieresbetweencombustablesandsourceofignition

FailureMode

Causes

Effects

Insufficientbarrierssuchas:
Dryingoutofnormally
saturatedmaterials(wet
towelsorsponges)additional
wetspongesnotutilizedper
normalpracticeorpolicy.
Additionalsalinenotreadily
available.

Staffnotknowledgeable
Lengthofcaseexceeds
saturationpoint
Drytowelsorspongesnot
replacedwithsaturatedones

Sourceofignitioncould
triggeraburninthepatient
Drapingcouldeasilyignite
Spongesallowedtodryout
couldeasilyignite

Occ Det Sev RPN Actions


2

2 Considerhavingsalineon
sterilefieldforall
procedures,whether
typicallyusedornot

Occ Det Sev RPN Actions


9

27 SalinestockedinallOR
suites,Alarmforhumidity
fallingbelow35%,ORdoors
keptclosedatalltimes

Occ Det Sev RPN Actions


2

32 Stockfireextinguishersin
eachORoratminimumin
ORcorearea

Occ Det Sev RPN Actions


1

1 Stockfireextinguishersin
eachORorCore

Occ Det Sev RPN Actions


2

4 Followpoliciesand
proceduresinplace
Provideadditional
competenciesforstaff

CalculatedTotals
TotalRiskPriorityNumberfortheprocess
Occ: LikelihoodofOccurrence(110)
Det: LikelihoodofDetection(110)

66

NOTE: 1=VerylikelyitWILLbedetected
10=VerylikelyitWILLNOTbedetected

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

Annotation
None