9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

2014BloodTransfusions
PhoenixIndianMedicalCenter
Phoenix,Arizona,UnitedStates
PublicHealth

Aim:Improvetheprocessfororderingbloodtransfusions.
ProcessData
Date:06/18/2014
Step

Description

Physicianandpatientdiscussnecessityofbloodtransfusion.

FailureMode

Causes

Physicianandpatientdonot Busyforget
discussnecessitymightbe
impossibletoobtaininformed
consent.
Step

Description

Informedconsentobtained.

FailureMode

Causes

ViolationofP&Pnoconsent BusyForget
obtained.

Effects
Delayinobtaininginformed
consent

Effects
Placesorganizationin
jeopardy.Patient'srightto
haveinformedconsent,
violated.

Step

Description

PhysicianordersType&Screen,orTypeandCrossmatch.

FailureMode

Causes

Effects

Papersystemsubjectto
errors.

Paperlost,cannotread
handwriting,communication

Numerouserrorsofomission
/commission.Delayin
transfusion.

Step

Description

RNcompletespaperformSF518,SectionIforType&Screen,or
Type&Crossmatch.

FailureMode

Causes

Effects

Paperworkerror.

Busy,distracted

Mistakeinorder.

Step

Description

RNattachesinformedconsenttoSF518anddeliverstoLaboratory.

FailureMode

Causes

Effects

Incompletepaperwork
delayeddeliverytoLab,
paperworkmisplaced

Distracted,busy,paperwork
lostinLab

Delayintransfusion/patient
care.

Step

Description

Labverifiespaperworkandobtainsbloodsamples.

FailureMode

Causes

Misplacedpaperwork.Error
Hectic,busy,humanerror.
inverification.Bloodsamples
delayedornotordered.

Effects
Delayintransfusion/patient
care.

Step

Description

Bloodtyped&compatibilitytestsdone,LabupdatesSF518,Section
IIandattachesformtoblood.

FailureMode

Causes

Effects

Testnotcompleted
paperworklost,incomplete
paperworknotattachedto
blood.

Hectic,busy,humanerror

Delayintransfusion/patient
care.

Step

Description

LabissuesbloodtoRNandrecordstimeissuedonSF518,Section
III.

FailureMode

Causes

Effects

Labissueswrongblood.

Humanerror

Possibletransfusionerror

Occ Det Sev RPN Actions

1

1 Followpolicy&procedurefor
bloodtransfusions.

Occ Det Sev RPN Actions

1

5 Checklistforitemsto
completefortransfusions.

Occ Det Sev RPN Actions

5

360 Stoppapersystemof
orderingbloodandutilize
E.H.R.

Occ Det Sev RPN Actions

2

80 Movetopaperlessorder,use
E.H.R.

Occ Det Sev RPN Actions

2

50 Stoppaperorderingmove
orderingoftransfusionsto
E.H.R.

Occ Det Sev RPN Actions

2

80 MovetoE.H.R.orderingof
transfusions.

Occ Det Sev RPN Actions

2

40 MovetoE.H.R.orderingof
bloodtransfusions.

Occ Det Sev RPN Actions

1

10

10

100 MovetoE.H.R.orderingof
bloodtransfusions.

CalculatedTotals

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=17742&ScenarioId=19882&Type=1

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

TotalRiskPriorityNumberfortheprocess

716

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=17742&ScenarioId=19882&Type=1

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