9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

PhysicalTherapyFallPrevention
SellsIndianHealthServiceHospital
Sells,Arizona,UnitedStates
HospitalCommunity

Aim:Todecreaseoutpatientfallsby50%in12months
ProcessData
Date:02/19/2014
Step

Description

Outpatiententersfacility

FailureMode

Causes

Effects

Adminstaffatfrontdesk
cannotdeterminefallrisk

Noassessmenttoolor
educationforclericaland
adminsitrativestaff

Nofallriskassignedto
patients

Step

Description

Patientfillsoutoutomemeasuresforspecificreferralproblem

FailureMode

Causes

Noinfotakenfrompatient
Notoolforriskassessment
specificallyregardingfallrisk forpatientspresentingwith
gaitdeviceissueonly.

Effects
Patientsreferredforcanes
gounassessedforfallrisk

Step

Description

Patientsitsinwaitingroomandwaitstobecalledinbythereapistfor
evaluationandtreatments

Step

Description

Patiententersclinicaltreatmentarea

FailureMode

Causes

Noassessmentoffallrisk
duringevaluation

Failureofstafftousean
Patientsatriskforfallgo
approipriateriskassessment unassessed
tool

Step

Description

Patientleavestreatmentarea

FailureMode

Causes

Patientnotidentifiedasafall Nofallrisktoolemployed
risk

Effects

Effects
Highriskoffallathomeorin
theclinic

Occ The Yourself RPN Actions

5

10 200 Initiatescreeningtoolto
allpatientscomingfor
ambulationdevices
withoutorderfor
physicaltherapy
balanceprogram

Occ The Yourself RPN Actions

10

10 100 Anypatientreferredto
PTforcaneorcrutch
issuewillfilloutabrief
questionnairedetailing
iftheyhavehadfallsin
thelastyearandifso,
howmanyandwhat
wastheinjurythewy
sustained.yesanswers
willpromptmessageto
primarycaredoctor

Occ The Yourself RPN Actions

4

10 360 Allpatientswith
outpatientDiagnosisof
difficultywalkingor
weaknessgetscreened
withabalance
assessmenttoolsuchas
theTinetti,Berg
balanceorGetupand
gotool.

Occ The Yourself RPN Actions

10

10 500 Allpatientwhoareat
riskforfallbyvirtueof
theirriskfactors
presentandthereason
forreferralget
screenedbyatherapist.
Patientsreferredfor
issueofgaitdeviceget
screenedby
administrativestaffwith
questionnaiirethat
alertsPTtoco

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1160

Occ:
It:

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

10=VerylikelyitWILLNOTbedetected

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

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=16974&ScenarioId=19187&Type=1

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

Annotation
None

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=16974&ScenarioId=19187&Type=1

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