9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

RespiratoryEtiquetteInfectiouspatients
KirbyHospital
Monticello,Illinois,UnitedStates
HospitalCommunity

Aim:Reducetheriskofrespiratorytransmissionofinfectiousprocessesfrompointofadmissionthroughthecourseofapatientsstay.
ProcessData
Date:07/10/2009
Step

Description

PatientarrivesEDregistrationarea

FailureMode

Causes

Effects

Patientpresentswith
respiratorysymptomsdoes
notreceiveinstructionsto
maskandusehandhygiene

Processnotclearto
registrationstaff.
Processtoaskquestionsnot
inplace.
Confusionwetherregistration
ortriagestaffshouldask
questions

Goestowaitingarea
unmasked.
Patients/visitorsinwaiting
areaexposed.
Triage/EDstaffexposed.

Patientrefusestodonmask
andpreformhandhygiene

Languagebarrier
Patientembarrassed.
Patientclaustrophobic
Patientconditionwillnot
toleratewearingamask.

Goestowaitingare
unmasked.
Otherpatients/visitors
exposedtoinfectious
process.
Hospitalstaffexposed.

Nomasksorhandsanitizer
available

Suppliesnotreordered
PatientreportstoEDor
Respiratorykiosknotrefilled waitingareaunmasked

Step

Description

PatientinEDwaitingarea

Occ Det Sev RPN Actions

10

10

100 Registrationstaffeducated
onaskingquestions
regardingrespiratory
symptoms
Developepatient
questionaireaddressing
respiratorysymptoms
Educateregistrationstaffto
instructallrespiratory
patientstodonmaskand
usehandhygiene

10

80 Signagetoalertpatientswith
respiratoryillnessthatthey
willberequiredtowear
maskinenglishandspanish.
Stafftowearappropriate
PPE.
Staffclearonhowtoinstruct
patientsandreinforce
behavior.
Registrationstaffclearon
howtonotify

10

50 MaintainparlevelsofPPE
andhandhygienesuppliesat
alltimes

FailureMode

Causes

Effects

Patiententerwaitingroom
withrespiratorysymptoms
andnotwearingmask

Patientnotmaskedat
registration

Patient/visitors/staff
exposed/contaminated

10

10

100 Assureregistrationarea
personnelareknowledgable
regardingtheir
responsibilitiestomask
patients

Patientnoncompliantwith
respiratoryprecautions

Lackofnecessaryspacefor
socialdistancing
Languagebarrier/cognitive
impairment
Deterioratingrespiratory
conditioncannottolerate
mask

Possibletransmissionof
infection
Risktoother
patients/visitors/staff

10

10

100 Redesigntriage/waiting
room
Cohortallrespiratory
patientsinseparatewaiting
area
Reeducateandreinforce
respiratoryetiquette

Step

Description

PatientinEmergencyDepartment

Occ Det Sev RPN Actions

FailureMode

Causes

Effects

Staffunawareofneedfor
respiratoryprecautions

Lackofeducationon
respiratoryetiquette
Patientnoncompliantwith
respiratoryetiquette
Signagenotvisibleondoor
Nocomputerwarnings
Isolationprecautionsnot
notedonwhiteboard

Exposure/contaminationof
triageandEDstaff
Exposure/contaminationof
supportstaff(lab,xray,
housekeeping,etc)

10

StaffrefusaltodonPPE

Staffuneducatedon
importanceofutilizingPPE

Exposureofstaff,other
patientsandvisitors

10

FailureMode

Causes

Effects

Patienttransportedto
auxillarydepartmentsfor
furthertestingwithouta

Communicationbreakdown
nocomputernotificationof
isolationprecautions

Unnecessary
exposure/contaminationof
additionEDstaff,support

Step

Description

Patienttransport

Occ Det Sev RPN Actions

90 Staffeducationonstrict
enforcementofrespiratory
etiquetteandisolation
precautions.
Appropriatesignageplaceon
examroomdoor
Whiteboardupdatedina
timelymanner
400 Reeducatestaffon
importanceofPPE
Addnegativeconsequences
tononcompliance

Occ Det Sev RPN Actions

10

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=8999&ScenarioId=10486&Type=1

10

100 Appropriatesignageplaced
onexamroomdoorand
chart

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9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

mask

Nosignageuponentryto
examroomforneedof
precautions
Duetoclinicaldeterioration
unabletotoleratesurgical
mask

Step

Description

PatientArrivestoInpatientUnit

FailureMode

Causes

servicesstaff,auxillary
departments,family,patients
andvisitors

Effects

computerordersentered
appropriatelydesignating
isolationprecautions

Occ Det Sev RPN Actions

Respiratoryisolation(Droplet Screeningprocessbroke
orAirbornedependingon
downonintake.
etiology)notinstituted
Staffunawareofneedfor
respiratoryprecautions.
Communicationbreakdown
StaffrefusaltowearPPE

Furthercontaminationof
inpatientunitpersonneland
patients.

10

560 Continuingstaffeducationon
isolationprecautions,
respiratoryetiquetteand
PPE.

Staffunprotectedwhenthey
enterroomforinitial
assessment

Appropriatesignagenot
posted

Staffunawareofneedfor
PPE

10

350 Reinforceimmediate
instatementofisolation
precautions

Auxillarystaffenterspatient
roomunprotectedorwith
inappropriateuseofPPE

Isolationprecautionsignnot
immediatelyposted

Exposure/contaminationof
additionalstaff

10

400 Postappropriateisolation
precautionsimmediately
uponadmission

Inadequatenumberof
isolationcartsor
inadequatelysupplied

Notenoughcarts
Notrestackedafterlastuse

NotsuffiucientPPEavailable
toprotectstaffandvisitors

10

320 Restockisolationcartsdaily
Purchasemoreisolation
cartsandstockwith
sufficientparlevels

FamilynotusingPPEand
otherinfectioncontrol
precautions

Familynoteducatedin
infectioncontrolmeasures
Nosignageposted/visible

Riskofspreadofinfectionto
familyandcommunity

10

60 Possiblevisitation
restrictions
Family/visitorseducatedon
appropriateisolation
precautions

Inappropriatebed
assignment

Patientcohorted
inappropriately

Additionalexposureofother
patients,staffandvisitors

10

50 Pttobeplacedinprivate
roomsorcohortedwithlike
symptomsandorganismsif
necessary

Step

Description

PhysicianOrderstates"NoNeedtoIsolate"

FailureMode

Causes

Effects

Patientwiths/sofrespiratory
infectioncontinuesNOTtobe
isolatedwithcontinued
contaminationtoallwhovisit
theroom.

Nonadherencetopolicyfor
maskingallpatientsand
isolatinguntilantibiotic
effective.Notmanaging
conflictwithphysicians.

Continuedcontaminationof
allwhohavecontactwith
patient.

Occ Det Sev RPN Actions

7

10

10

700

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

3460

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=8999&ScenarioId=10486&Type=1

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