9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

ScopeCleaningProcess
Mt.OgdensurgicalCenter
Ogden,Utah,UnitedStates
Other

Aim:Decreaseexposureofpatientstodiseasebyensuringpropercleaningofscopes.
ProcessData
Date:10/13/2008
Step

Description

InProcedureRoomsuctionfluidthroughbxlumenandirrigationtube

FailureMode

Causes

Failuretosuctionalllumens. Shortstaffed.
Omittingthisstep.
Hurryingforquickturnover
time.

Effects
Contaminationof
instruments.
Spreadofdisease.

Step

Description

Disconnectscopeandplacesafetycap.Safetycapmustbeonatall
times.

FailureMode

Causes

Effects

Notplacingsafetycapon
scope.

Tehscopewillberuined.

Costtothefacility.
Lengthenedtimeandpossibel
cancelofscheduledpatients
thatday.

Step

Description

Performleaktestsonscope(dryandwet)

FailureMode

Causes

Effects

Skippedthisstep.
Performedincorrectly.

Shortstaffed.
Hurryingforquickturnover
time.
Noteducatedproperlyto
process.

Failureofprocedure,unable
tocompleteifleakage
occurs.

Step

Description

Placescopeinbinwithsoapandwater.

FailureMode

Causes

Failuretousesoapand
water.
Omittingthisstepall
together.

Rushingtoturnoverroom
Possibleincreaseofbuildup
fornextcase.Lackofproper inthescopes.
education.
Riskofdiseasefrom
contaminatedscope.

Step

Description

Usesoapyspongestoremovegrosscontamination

Effects

FailureMode

Causes

Effects

Failuretocompletelyclean.
Omittingthisstep.

Shortstaffed.
Hurryingforquickturnover
time.
Failuretoinstructstaffin
propertechnique.

Crosscontaminationbetween
patients.

Step

Description

Passbrushthroughthe3portsandthebuttonsatleast3times.

FailureMode

Causes

Failuretobrushenoughtimes Lackofpropereducation.
fortheportstobeclean.
Tryingtohurrytogetthe
scopeinsonicfornextcase.

Step

Description

PlacebuttonsinthecontainerofOPA.

Effects
Buildupofbodyfluidsfrom
patientmaycauseinfection
inotherpatients.
Spreadofdiseasetoother
patients.

FailureMode

Causes

Effects

Omittingthisstep.

Mayloosethebuttonsinthe
sonicifnotplaceinthe
propercontainer.

Nothaveingenoughbuttons
toperformthecase.

Step

Description

FlushsoapywaterthrougheachportX2

FailureMode

Causes

Failuretoflushwithsoapy
water.

Forgetwhichstepyouareon Notallofthecontaminants
intheprocess.
willberemoved.

Effects

Occ Det Sev RPN Actions

4

10

80 Staffeducation.
Annualcompetency
checklist.

Occ Det Sev RPN Actions

6

10

240 Safetycapisthefirstthing
donetothescopebeofre
removingitfromthe
procedureroom.

Occ Det Sev RPN Actions

4

16 Education.
Competencychecklist
yearly.

Occ Det Sev RPN Actions

4

10

160 Havingpropereducation
classeswithemployee'sto
makesuretheyunderstand
theimportanceofthisstep.

Occ Det Sev RPN Actions

4

16 Education.
Insistontakingenoughtime
toproperyprocessthe
scopes.

Occ Det Sev RPN Actions

4

10

160 Havepropereducation
classeswiththeemployee's
toexplaintheimportanceof
thisstepforpatientsafety.

Occ Det Sev RPN Actions

4

10

160 Continuingeducationofthe
employee's.

Occ Det Sev RPN Actions

3

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=7637&ScenarioId=8914&Type=1

84 Ifyouforgetwhichnumber
youareon,doanextra

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
flush.

Step

Description

FlushrinsewaterthrougheachprotX2

FailureMode

Causes

Effects

Failuretorinseallthesoap
out.

Youforgetwhichstepyou
wereon.

Soapisleftintheportsand
scopecausingscumtooccur
inthescope.Inthelongrun,
thescopewillberuined.

Step

Description

10

CidexflushthrougheachportX2

FailureMode

Causes

Failuretoflushcidexthrough Forgethowmanytimesyou
eachporttwice.
haveflushed.
Step

Description

11

OPA12minutesoakSETTIMER

Effects
buildupofcontaminantsand
spreadofinfection.

FailureMode

Causes

Effects

Failuretosoakscopelong
enough.

Forgettosetthetimer.

Lengthoftimeisnotlong
enoughtokillallpotential
pathogens.

Step

Description

12

RinsewaterflushthroughallportsX4

FailureMode

Causes

Effects

Failuretoflushandrinse
scopewell.

Forgetorgetcalledaway
beforecompletionofrinse.

Cidexleftinscope.Possible
exposuretopatient.

Step

Description

13

AlcoholrinsethrougheachportX1

FailureMode

Causes

Omittingthisstepfromthe
cleaningprocess.

Hurringtoturnovertheroom Omittingthisstepwillcause
fornextcase.
thescopetobewetinside
longerthanshouldbeand
couldcausemoldinscope.

Effects

Step

Description

14

Wipedowntheoutsideofthescopewithalcoholandthenhangto
dry.

FailureMode

Causes

Effects

Omittingthisstepofthe
process.

Inahurrytogetthescope
cleanedandhungupforthe
nextcase.

Leavesthescopewetfrom
thesonicmachinewhenhung
incabinetforstorage.

Step

Description

15

Connectthescopetotheairtankandblowouteachport.

FailureMode

Causes

Effects

Omittingthisstep.

Pooreducation.
Distracted.

Nothaveingtheairblow
throughthescopeatalltimes
inthecabinetcouldallowfor
dusttogetintoandonthe
scope.

Step

Description

16

StoreinclosethangingwithCAPOFF.

FailureMode

Causes

Effects

Failuretoremovethesafety
capwhenhangingincloset
forstorage.

Inahurry.forgettoremove
thecap

Failuretoallowmoistureto
drywillcauseshortsinthe
fiberopticsandthiswill
causedifficultywhenyouuse
itthenextweek.

Occ Det Sev RPN Actions

5

200 Ifindoubt,rerinse.

Occ Det Sev RPN Actions

3

10

90 Ifindoubt,beginsteps
again,orflushanextratime.

Occ Det Sev RPN Actions

3

10

240 TimermustbesetPRIORto
leavingthecleaningroom.

Occ Det Sev RPN Actions

3

60 Ifindoubt,rerinseone
moretime.Thealcoholrinse
willalsohelpifonerinseis
forgotten.

Occ Det Sev RPN Actions

4

10

160 Havepropertrainingand
educationaboutthesonic
machineandtheimportance
offollowingprocedure.

Occ Det Sev RPN Actions

4

10

160 Continueingeducationabout
thecleaningprocessofthe
scope.

Occ Det Sev RPN Actions

4

128 Educatethestaffaboutthe
cabinetandhowtohookup
theairfilter.

Occ Det Sev RPN Actions

5

245 Placesignoninsideof
cabinetstatingtoremember
toremovecapforstorage.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

2199

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=7637&ScenarioId=8914&Type=1

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