9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

TrackingLabs,OB/Gyn
UnitedStates
Professional/MedicalSchool

Aim:Reduceriskofdelayedormissedtreatmentduetomissedlabreports
ProcessData
Date:04/15/2005
Step

Description

Labworkorderedinclinic

FailureMode

Causes

labmissed

Norecord/promptofpending treatmentdelay/poor
labs
maternalfetaloutcome

Step

Description

Patientpresentstolab

Effects

FailureMode

Causes

Effects

Nospecimencollected/no
testsrun

Patientfailstogotolab

missedproblem/treatment
delaymostlikelydetected
after4wks.

Step

Description

Labprocess(UMC,notTTUHSCprocess)

Step

Description

Labreportgenerated

FailureMode

Causes

misplacedreport

Effects
treatmentdelay

Step

Description

ClinicNApicksupreportsat7:30eachmorning

Occ Det Sev RPN Actions

5

Occ Det Sev RPN Actions

8

Causes

Effects

Reportnotavailable

Routedwronginlab

treatmentdelay

Nolabpickup

NAstaffhassickday,other
delayof1/2to1dayseeing
staffmaynotbedesignated, reports
mayforget

Reportspickedupinclude
reportstowrongphysician,
wrongclinicsite

incorrectlylabeledlab
requests,labprocess

Step

Description

NAlooksforpatientID/MRinIDX

Step

Description

LabreportstampedforMDsignature

FailureMode

Causes

Effects

Labnotstamped

nostampavailable/staff
unfamiliarwithprocess

nopromptforMD/Provider
notes

Step

Description

DivideintoOBandGYN

Step

Description

OB:obtaincliniccharts

FailureMode

Causes

Effects

Chartnotavailable

Chartmaybeinotherdept
clinicorinMD'soffice

delayuntilchartfound,
applicableptinformationnot
available

FailureMode

Causes

Effects

missing/unavailablechart

centralMRinuseinother
clinic

patientinformationnot
availableforfollowupor
clinicaldecisionmaking

Step

Description

10

GYN:ordercentralMR

Step

Description

11

Attachlabreporttofrontofchart

Step

Description

12

PlacechartwithreportinMD/provider'sbox

200

Occ Det Sev RPN Actions

FailureMode

Addstostafftime,effort
sortingclinicapplicablelabs

125 Keepyellowcopy,nurses
review1Xwk

125

Occ Det Sev RPN Actions

25
2 Backupstaffassigned

28

Occ Det Sev RPN Actions

1

1 NotifyNurseManagerifno
stampavailable

Occ Det Sev RPN Actions

2

20

Occ Det Sev RPN Actions

5

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=1309&ScenarioId=1686&Type=1

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureMode

Causes

Effects

physicianoutornoclear
designeetoreview

notcommunicatedtoNA
handlinglabreports

delayedreview

Step

Description

13

MD/Providerreviewslabreports

Step

Description

14

MD/Providerinitials/indicatestypeoffollowupneeded

FailureMode

Causes

Effects

MDfailstosign/initial,
indicatefollowup

interruptionstoprocess

noindicationofintended
treatmentorinstructionsfor
followup

Step

Description

15

MDplacesinrespectivenurse'sbox

FailureMode

Causes

Effects

delayedresponseobtaining
chart

nurseoutsick,vacation,
etc.

delayedpatient
notification/delayed
treatment

Step

Description

16

NursecallsorsendsletterasindicatedbyMD

FailureMode

Causes

Effects

patientnotnotifiedfor
followup

patienthasnophone,
disconnectedphone,wrong
address

patientnot
contacted/potentialtreatment
delay

Step

Description

17

AttemptscallsX3,thenlettersent

Occ Det Sev RPN Actions

5

20 Prioritizeabnormallabsand
consultschedulefor
coverage.

Occ Det Sev RPN Actions

1

5 NursequestionsMD
regardinginstructionsfor
followup

Occ Det Sev RPN Actions

5

10 Teamworkhasbeen
emphasizedtocoverall
tasks

Occ Det Sev RPN Actions

8

80 IfOBpatienthasSTD,health
deptnotified,tracksdown
patientifpossible.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

691

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

10=VerylikelyitWILLNOTbedetected

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

Annotation
None

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=1309&ScenarioId=1686&Type=1

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