FMEA Forms

7/30/2019 FMEA Forms

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FAILURE MODE EFEECTS ANALYSIS

PROCESS STEPS: Describe the process graphically, according to your policy and procedure for the activity, and number eachone. If the process is complex you may want to select one process step or sub-process to work on.

DIRECT ADMITS

1 2 3 4 5

MD Decision to Obtain Orders Bed Assignment Registration

Admit

List the sub-processes for each process step and letter

Sub process steps Sub process steps Sub process steps Sub process steps Sub process steps

A. MD/Office staff call A. Phone A. Determine bed type A. Enter Data A. Call transport or

hospital - why? direct patient to area

B. Verification of bed B. Fax B. Check Bed Availability B. Verify Accuracy B. Call unit to come

availability with? of data in system and get patient

C. C. Send with patient C. Notify unit of bed C. Complete Advance C. Transport pt to

assignment Directives/Rights/HIPPA appropriate care area

D. D. D. D. D.

E. E. E. E. E.

F. F. F. F. F.

Transport or Direction

To Unit


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FAILURE MODE EFFECTS ANALYSIS

SUB-PROCESS STEPS: Graphically describe the sub-processes for each process step and then list the possible failure modes for each one

If the process is complex you may want to select sub-process to work on.

PROCESS: MD DECISION TO ADMIT

A B C D E

MD/Office Staff Verification of Bedcalls Hospital Availability

Failure Modes Failure Modes Failure Modes Failure Modes Failure Modes

1. Wrong person 1. No bed available 1 1 1contacted with info2. Patient arrives 2 2 2 2

without prior notice3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

6 6 6 6 6


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SUB-PROCESS STEPS: Graphically describe the sub-processes for each process step and then list the possible failure modes for each one


PROCESS: OBTAIN ORDERS

A B C D E

MD/Office Staffphones/faxes/

gives orders topatient


1 No orders received 1 1 1 1

2 Orders incomplete 2 2 2 2

or illegible3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

6 6 6 6 6


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SUB-PROCESS STEPS: Graphically describe the sub-processes for each proces step and then list the possible failure modes for each one


PROCESS: BED ASSIGNMENT

A B C D E

Determine Bed Check Bed Assign BedType Availability


1 Incorrect assignment 1 No bed available 1 Bed assignment person 1 1made (gender, age, dx) (high census, type, etc.) not available2 2 Overlapping bed 2 No bed assignment 2 2

assignment made3 3 Bed not clean/bed broken 3 Patient arrives to floor 3 3

without bed assigned

4 4 Late discharges 4 4 4

5 5 5 5 5

6 6 6 6 6


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PROCESS: REGISTRATION

A B C D E

Register Patient Enter Data Advance Directives Patient ID Documents toVerify Accuracy of Consents/HIPAA Care Area

Data already insystem


1 Clerk not available 1 System down 1 1 Patient incorrectly 1 Documents notidentified (banded) available to caregivers

2 Patient reports to wrong 2 Incorrect info entered 2 2 Patient not "banded" 2

area3 3 Patient unable to give or 3 3 3

verify accuracy

4 4 4 4 4

5 5 5 5 5

6 6 6 6 6


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PROCESS: TRANSPORT

A B C D E

Call Transport Direct Patient to Call unit to come & Transport to UnitCare Area get patient


1 Transport not available 1 Patient gets lost 1 Staff not available 1 Patient arrives without 1to get patient being registered

2 Transport equipment not 2 No one available to 2 2 Patient arrives without 2

available receive patient unit notification3 3 3 3 Patient arrives and bed not 3

ready

4 4 4 4 4

5 5 5 5 5

6 6 6 6 6


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HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET

Process Step: MD Decision to Admit

Potential Failure Mode 1. Wrong person 2. Patient arrives 3. No bed available

(what could go wrong) contacted with without prior notice

informationEffect (what could happen) Delay in care Delay in treatment Delay in treatment

Customer dissatisfaction Treatment errors Customer dissatisfaction

Increased risk of bad Increased risk of bad outcomes Loss of revenue

outcomes Customer dissatisfaction Patient Safety/Risk Issue

Staff overburdened Increased risk of noso.

infections (rush to clean)

Patient in inappropriate

level of care

Severity: 1 = no harm; 2 = temporary harm; 3 = permanent harm;

4 = Death/Major loss of function

Potential Cause(s) 1. Unclear hospital 1. MD/Office staff too busy 1. High census

(why the failure could occur - list all possibilities process to call or forgets 2. Delay in cleaning

for each failure mode and conduct analysis for all failure modes within the 2. Noncompliant MD's 2. Unclear hospital process 3. Discharge delays

scope of this FMEA) 3. Lack of Education 3. Noncompliant MD/Office 4. Inapproriate utilization

regarding process staff 5. Communication

Probability: 1 = remote; 2 = uncommon; 3 = occasional; 4 = frequent

Current Control Measure

Detectability: 1 = Very Likely; 2 = Likely; 3 = UnLikely; 4 = Very Unlikely

Hazard Score (RPN = Severity x Probability x Detectablility)

Decision: Proceed or Rationale for Stopping based on score or

explanation

Action (Eliminate, Control or Accept)

Description of Intervention

Outcome Measure

Person Responsible

Management Concurrence (Yes or No)Implementation Time Frame/Date Due


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HEALTHCARE FAILURE MODE EFFECTS ANALYSIS WORKSHEET page 2

Process Step: Obtain Orders

Potential Failure Mode 1. No orders 2. Orders incomplete

(what could go wrong) received or illegible

Effect (what could happen) Delay in treatment Delay in treatmentIncorrect treatment Incorrect treatment

Increased risk of bad out-

comes

Customer Dissatisfaction

Increased LOS

Increased work load for

staff



Potential Cause(s) MD too busy Admit status not documented

(why the failure could occur - list all possibilities MD noncompliance or documented incorrectly

for each failure mode and conduct analysis for all failure modes within the Patient loses them Fax copies unreadable

scope of this FMEA) Fax busy/malfunction Handwriting illegible

Lack of education (what's

required by Reg. Agencies)






explanation



Outcome Measure

Person Responsible

Management Concurrence (Yes or No)Implementation Time Frame/Date Due


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Process Step: Bed Assignment

Potential Failure Mode 1. Incorrect assign- 2. No bed available 3. Overlapping bed

(what could go wrong) ment made (gender, (high census, type, etc) assignment

age, diagnosis, etc.) (See MD Decision toAdmit Process)

Effect (what could happen) Customer dissatisfaction Customer dissatisfaction

Spread of infection Delay in treatment

Delay in treatment



Potential Cause(s) Manual/decentralized Manual/decentralized

(why the failure could occur - list all possibilities process process

for each failure mode and conduct analysis for all failure modes within the Inaccurate info Multiple contacts

scope of this FMEA) Communication failure Inaccurate recordkeeping

by units

Communication failure






explanation



Outcome Measure

Person Responsible

Management Concurrence (Yes or No)

Implementation Time Frame/Date Due


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Potential Failure Mode 4. Bed not clean/bed 5. Late Discharges 6. Bed assignment

(what could go wrong) broken person not available

Effect (what could happen) Increased risk of infection Hospital on diversion due to Customer dissatisfaction

Incresed risk of injury no beds Delay in treatment

Customer dissatisfaction Loss of revenue



Potential Cause(s) Unit not communicated Late rounding by MD's No back-up system in

(why the failure could occur - list all possibilities with Env. Services that Awaiting diagnostic reports place

for each failure mode and conduct analysis for all failure modes within the patient discharged

scope of this FMEA)






explanation



Outcome Measure

Person Responsible




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Potential Failure Mode 7. No bed assign- 8. Patient arrives to

(what could go wrong) ment made floor without bed

assigned

Effect (what could happen) Delay in treatment Delay in treatment

Customer dissatisfaction Customer dissatisfaction



Potential Cause(s) Bed unavailable Communication Failure

(why the failure could occur - list all possibilities Not staff priority

for each failure mode and conduct analysis for all failure modes within the Lack of staff accountabil-

scope of this FMEA) ity/responsibility

No request received






explanation



Outcome Measure

Person Responsible




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Process Step: Registration

Potential Failure Mode 1. Registration Clerk 2. Patient reports to 3. System down

(what could go wrong) not available wrong area

Effect (what could happen)



Potential Cause(s)

(why the failure could occur - list all possibilities

for each failure mode and conduct analysis for all failure modes within the

scope of this FMEA)






explanation



Outcome Measure

Person Responsible




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Potential Failure Mode 4. Incorrect info 5. Patient unable to give 6. Patient

(what could go wrong) entered or verify accuracy of incorrectly identified

info "banded"




Potential Cause(s)



scope of this FMEA)






explanation



Outcome Measure

Person Responsible




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Potential Failure Mode 7. Patient not 8. Documents not avail-

(what could go wrong) "banded" - able to staff (i.e., consent

identified to treat, etc.)




Potential Cause(s)



scope of this FMEA)






explanation



Outcome Measure

Person Responsible




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Process Step: Transport

Potential Failure Mode 1. Transport not 2. Appropriate transport 3. Patient gets lost

(what could go wrong) available equipment not available




Potential Cause(s)



scope of this FMEA)






explanation



Outcome Measure

Person Responsible




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Potential Failure Mode 4. No one available 5. Staff not available 6. Patient arrives

(what could go wrong) to receive patient to come and get patient without being

registered




Potential Cause(s)

(why the failure could occur - list all possibilitiesfor each failure mode and conduct analysis for all failure modes within the

scope of this FMEA)






explanation



Outcome Measure

Person Responsible




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Potential Failure Mode 7. Patient arrives 8. Patient arrives and

(what could go wrong) without unit being bed not ready

notified




Potential Cause(s)

(why the failure could occur - list all possibilitiesfor each failure mode and conduct analysis for all failure modes within the

scope of this FMEA)






explanation



Outcome Measure

Person Responsible

