Failure Mode and Effects Analysis Go to the website Institute for health improve

Question

Failure Mode and Effects Analysis

Go to the website Institute for health improvement http://app.ihi.org/Workspace/tools/fmea/ Use the tool provided to look for a weak link in the quality chain. Use their Template to look for a weak link in the quality chain. Look beyond direct care for things that could contribute to the error. Think organizationally to trace the problem back to the original cause. Rate possible events that could go wrong. Use any community in the US. Use the FMEA (Failure Mode and Effects Analysis) Template from the Institute of Healthcare Improvement. This is the link. http://app.ihi.org/Workspace/tools/fmea/

Explanation / Answer

Failure Mode and Effects Analysis :

Occ- Likelihood of occurence(1-10)

Det- Likelihood of detection (1-10)

1= very likely it will be detected

10= very likely it will not be detected

Sev- severity(1-10)

RPN - Risk Priority Number (Occ * Det * Sev)

Failure Mode causes effects Occ Det Sev RPN ICU tracking the wrong patient the patient identification is not confirmed by ICU with the floor nurse The wrong patient is monitored 2 2 10 40 known patient condition is not communicated normal condition of patient is viewed to be monitored patients that have tremors may activate alarm for "cannot analyze" ECG 3 2 2 12 patient not monitored properly electrodes not applied properly unnecessarily alarms are sounded 5 2 10 100 Batteries are not changed no knowledge of how often to change batteries patients improperly monitored. 5 1 5 25

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