9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

PatientFallPreventionSAFEProgram
OurLadyofLourdesHealthSystem
Camden,NewJersey,UnitedStates
HospitalTeaching

Aim:ReducetheNumberofPatientFallsby50percentin6months
ProcessData
Date:09/27/2007
Step

Description

Failuretoassessthepatient'sriskoffall.

FailureMode

Causes

Effects

Nursefailstoassessthe
patient.

Nurseistoohurried.

Riskofpatientfall.

25 NurseeducationoftheSAFE
practice/procedures/policies.

Failuretoprovideasafe
environment.

Roomcluttered,bed
/stretcherrailsinthedown
position,lightingpoor.

Patientriskoffall.

25 Maintainaclutterfreeroom,
appropiatesiderailsintheUP
position,leavenightlightor
bathroomdooropenedfor
additionalnighttimelighting.

Patientand/orfamilynot
educatedaboutthecultureof
safetyandthepreventionof
patientfalls.

Languagebarrier,brochures
nothandedtothepatient,
nursedidnotdiscusssafety
withthepatient.

Patientriskoffall.

40 UtilizetheTranslationLine,
accesstheSAFEbrochures,
nursetopatienteducation
forsafetyandtheprevention
ofpatientfalls.

Nurseunfamiliarwiththe
SAFEProgram.

NewNursetotheNursing
Riskofpatientfall.
Unit,theNursemaynothave
clinicalexperience.

125 Nurse/Staffeducation
abouttheSAFEProgram.

MorseAssessmentdoesnot
capturethecategoriesof
medicationsthatmay
contributetoanincreased
patientriskforfalls.

Electroniccomputersystem
doesnothavemedication
categoriesincludedinthe
Morseassessment.

125 Themedicationcategories
willbeaddedtotheMorse
assessment.

Step

Description

EvidencedBasedPracticesnotutilized.

FailureMode

Causes

Increasedriskofapatient
fall.

Effects

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

Personalalarmnot
Lackofnurserounding,lack
applied/bedexitalarmnotin ofpatientfallrisk
theONposition,Siderailsnot recognition.
padded,painmedicationnot
offered,toiletingnotoffered,
reducedlighting,personal
needsnotattended.

Patientriskoffall.

125 Educationandcomplianceof
thenurseforsafety
measures.

SAFEpreventionresources
limited.

SAFESuppliesnotavailable
onthenursingunits.

Patientriskoffall.

25 Nursingunitskeepparlevels
ofSAFEsupplies.Accessof
suppliesthroughSPD.

FailureMode

Causes

Effects

Failuretoprovideasafe
environment,failuretore
assessthepatient.

Lackofnursingexperience,
lackofnursingpractice,no
handoffcommunication,
failuretoassessfor
medicationrelatedchanges.

Patientriskoffall.

Step

Description

RepeatPatientFalls

Step

Description

Processnotstandardized.

FailureMode

Causes

Effects

Postfallassessmentnot
completed.

Differentforms.

Incompletepatientdata
collectionforfallinformation.

Occ Det Sev RPN Actions

8

10

640 Patientq1hourrounding,
utilizetheSBAR.

Occ Det Sev RPN Actions

5

25 Standarizedforms.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1155

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

10=VerylikelyitWILLNOTbedetected

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

Annotation

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=4885&ScenarioId=5940&Type=1

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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

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http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=4885&ScenarioId=5940&Type=1

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