Download - 2015 Med Surg Falls - Fmea Ssrmc
9/14/2015 Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19387&ScenarioId=21348&Type=1 1/2
Failure Modes and Effects Analysis (FMEA) Tool
2015 Med Surg Falls FMEA SSRMC
Shands StarkeStarke, Florida, United StatesHospitalCommunity
Aim: Reduce the rate of fall prevalence by 50%. (Falls per patient day)
Process Data
Date: 03/11/2015
Step Description1 Fall Risk assessment
Failure Mode Causes Effects Occ Det Sev RPN ActionsInaccurate fall riskassessment leads tounidentified risk
Inconsistent education tostaff members regarding useof fall risk tool
Patient at higher risk goesunidentified
5 4 7 140
Nurse does not give a yellowarm band
5 3 10 150
Step Description2 No implementation of Yellow Socks
Failure Mode Causes Effects Occ Det Sev RPN ActionsSlip/trip/fall Lack of precautions in place, no injury to severe 4 7 5 140
Step Description3 Technology/alarm failures
Failure Mode Causes Effects Occ Det Sev RPN ActionsAlarms non functional, notset or not available
Inattention, lack of resetsfollowing care, patienttampering, device failure
High risk patients may haveunintended OOB activitypossibly resulting in fall, nostaff awareness of activitydue to dependence on nonfunctioning alarm to alert.
4 7 5 140 Incorporate alarm test intoregular rounding, reviewalarm parameters andfunction as part of routinepatient evaluations
Alarm not set to Centralmonitoring
5 5 8 200 All bed alarms will be set to"Central Monitoring" for fallrisk patients.
Step Description4 Failure to report via SBAR
Failure Mode Causes Effects Occ Det Sev RPN ActionsFall risk not communicated 6 2 9 108
Step Description5 Medication Influences on Fall Risk
Failure Mode Causes Effects Occ Det Sev RPN ActionsOvermedication effects withnew medications orunfamiliar medications or incombination
Acute illness, pain control,physiologic effects andinteractions with newregimen
Progressive symptoms duringthe copurse of stay resultingin temporary increase in falllikelihood
2 6 5 60
Slowed or impairedjudgements ior reactions dueto medications and timing ofadministration
intreractions, timing andcombining of medications
Dizziness, ataxia falls 2 2 8 32
Step Description6 Environmental Concerns
Failure Mode Causes Effects Occ Det Sev RPN ActionsBedside clutter Lack of control of personal
itemsSlip, trip fall 3 1 5 15 Vigilance in maintaining
order, encourage patients tosend nonessentials home
Care items on wheels, IVpoles, bedside tables,tubings, electrical cords etc
Neccessary care items,subject to haphazardplacement
Slip, trips, falls 3 1 5 15
Unfamiliar environmentparticularly at night
Elderly confusion, lowlighting, need for bathroomuse
wandering, slips, trips falls 2 4 5 40
Calculated Totals
Total Risk Priority Number for the process 1040
9/14/2015 Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19387&ScenarioId=21348&Type=1 2/2
Occ: Likelihood of Occurrence (110)Det: Likelihood of Detection (110) NOTE: 1 = Very likely it WILL be detected
10 = Very likely it WILL NOT be detectedSev: Severity (110)RPN: Risk Priority Number (Occ × Det × Sev)
AnnotationNone