9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

StandardizationofEmergency(CodeCarts)
SAINTMARY'SHOSPITAL
AMSTERDAM,NewYork,UnitedStates
HospitalCommunity

Aim:ReducetheriskassociatedwithNonStandardizedEmergencyCrashCarts.
ProcessData
Date:08/31/2006
Step

Description

UtilizationoftheCodeCart

FailureMode

Causes

Effects

Lackofknowledgeofthe
Lackofcontinuouseducation, Delaysintheresponseand
CodeCartscontents,location andtrainingonthefamiliarity treatmentwilloccurdueto
andpurpose.
ofthecartscontents.
lackofknowledgeand
continuoustrainingeffecting
patientcareandpatient
safety.

Step

Description

Identifyessentialitemsinthecrashcart

FailureMode

Causes

Effects

Incompletelistofitemsinthe Manyitemsonthecartshave Itemsnotavailableor

crashcart.
beenaddedorsubtracted
incorrectduringemergent
fromminimalcart
conditions,severelyeffecting
requirements.
patientsafetyandcare.

Step

Description

Allcartsthroughttheorganizationarestandardized

FailureMode

Causes

Effects

Cartscontainingdifferent
items,thesedifferentitems
transferredfromonecartto
anothermayormaynotbe
compatible.

Cartsmaintainedindifferent
departments,refurbishing,
inventoryanditem
requisitionarenot
centralized.

Timelinessinlocating,and
administeringcareis
delayed.Incompatible
instrumentshaveanegative
impactonpatientcare.

Step

Description

Maintenanceandrefurbishmentafterusage

Occ Det Sev RPN Actions

8

576 Continuousandperiodic
educationandtrainingonthe
contentsandusageofthe
codecart.Ahospitalwide
codecartfairhasbeen
conductedtofamiliarizeall
concernedofthecontents,
usageandeachpersons
roleintheprocess.

Occ Det Sev RPN Actions

8

648 Allcartstobestandardized
withonecentralizedlocation
forrefurbishment,inventory
andaperiodicmaintenance
schedule.

Occ Det Sev RPN Actions

9

10

810 Ensureallcodecartsare
created,refurbished,and
maintainedbyacentralized
faciliatyordepartment,with
stringentguidelinesforthere
content.

FailureMode

Causes

Effects

Codecartsrefurbishment
doesnotoccurafterusage
andwillbemissingessential
items.Nooneresponsiblefor
delivery,maintenanceor
refurbishment.

Assignmentofadesignated
personorgrouptobe
responsibleforthedelivery,
maintenanceand
refurbishmentofthecode
cart.

Essentialmedication,or
instrumentsarenotavailable
foremergentcare.

FailureMode

Causes

Effects

Failuretoidentifyexpired
materials.

Identifythattheitemisinthe Faultyorineffective
cartandnotspecifically
instruments,ormediation
checkingeachitems
duetoexpiration.
expirationdate.

512 Periodicmonitoringand
inventoryofthecodecarts
bytheStoreroomtoensure
allitemsonthecartshave
validexpirationdates.
Pharmacykeepsalistofall
medicationontheCode
Cartsandtheirexpiration
date,andnursingisnotified
whenthesemedi

Personnelworkingoffof
differentchecksheetsfor
inventory

Independentandnon
centralizedmaintenanceand
upkeepofcodecartsspecific
todepartment.

576 Standardizationofallcode
cartsandacentralized
locationforrefurbishmentto
ensureallinstruments,
medications,suppliesare
compatibleandconsistent
throughoutthecart.Onecart
checklistwillbeutilizedfor
inventoryandrefurbishment.

Step

Description

Inventoryofallcarts

Step

Description

AssemblyofCrashCarts

Inabilitytotransfercarts,
equipmentandinstruments
fromdepartmentto
departmentdueto
incompatibilityissues.

Occ Det Sev RPN Actions

9

10

810 AssignedSecuritytodeliver
codecartstoPharmacy,and
theStoreroomfor
medicationintegrityand
inventoryrespectively.

Occ Det Sev RPN Actions

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureMode

Causes

Effects

InitialassemblyoftheCode
Cartsweredesigned
independentlybythe
individualdepartments.

Cliniciansareonlyfamiliar
withthecartsfromtheir
departmentbecausethereis
nostandardization.

Possibledelaysintreatment,
reducequalityofpatientcare
andsafety.

FailureMode

Causes

Effects

Allcliniciansarenot
familiarizedwiththe
EmergencyPocedures.

CodeTeamsandtheir
Poorresponsetimeduring
responsibiltiesarenotclearly emergencysituations.
defined.

Step

Description

StaffEducation

Step

Description

EmergencyCartPolicyrevised

FailureMode

Causes

Effects

Currentcartpolicydidnot
identify,establishormonitor
theCodeCartsdesign,
maintenanceorprocess
performance.

Lackofadequatedirection
wasnotprovidedinthe
EmergencyCartPolicy.The
policydidnotcontainspecific
information.Taskswerenot
specificallyassignedto
specificindividualsorgroups.

Thishinderedtheoperational
effectivenessofthe
organization.Unclear
directionmakesitdifficultto
establishoperational
guidelines.

Occ Det Sev RPN Actions

9

648 TherevampingofallCode
Cartswillbeconductedby
onecentralizedlocation,with
itscontentsfirstbeing
approvedbyanewly
establishedCodeCart
committee.

Occ Det Sev RPN Actions

8

648 Ahospitalwidecodeteam
andMedicalResponse
Teamshavebeen
establishedtomonitorthe
performanceandprovide
continuousupdatingand
improvementtothe
educationandtrainingof
emergencyresponseteams
andtheirprocess.

Occ Det Sev RPN Actions

8

384 Newpolicycreated,aswell
asaCodeCartcommitteeto
reviseandupdatethepolicy
periodicallyorasneed.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

5612

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

10=VerylikelyitWILLNOTbedetected

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

Annotation
Change:Standardization

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