FAILURE MODE AND EFFECT ANALYSIS

(FMEA)

Sanglah General Hospital

2012

1
 Background
Reasons and Consideration
Handling for patient at emergency
department (patient safety), support
Sanglah vision and mission
Data shows that almost 30% of the patient
are really emergency the others can be
waiting to get the treatment
Some complains for bad services in ED
The velocity of patient treatment at
emergency department need to be
increased

2
 Background continued

Coordination meeting (ED doctors,

management, nurses, and installation that
involve) was held On 12 of January 2012 to
identify the problems at emergency
department
Triage standard is not clear
The flow of emergency patient is not clear
Resuscitation treatment is not handled by
resuscitation team
Emergency patient and false emergency patient
are still at the same room which can cause
unsafe condition for the patient it self

3
On 20 of January 2012, there was a
meeting (ED doctors, management,
nurses, installation, and Directors) ,
Sanglah hospital president director agreed
to redesign the services at emergency
department
On February 2012, the team work for the
first step of FMEA.

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 FMEA Team (Nutolen):
Dr. Semara Jaya, MM(Coordinator)
Ken Wiriani, SE, MRM (Secretary)
Dr. Krisna Wibawa, SpB (Member)
Dr. Tri Virgowati (Member)
Dr. Agus Jayendra (Member)
Eka Supraptiningsih (Member)
Budiarsana (Member)
Alasan Pemilihan tim, PPI?, IPSMNP?IPSPGS?PE? Farmasi?

5
 Patient Flow Chart
(pakai alur ISO)
Patient come to
Emergency

No (Vihicle access)
Can Walk?
Patient Transfer (salin
Yes (Pedestrian access) alur IGD)

Triaged by doctor Triaged by doctor

Level 3,4,5 Level 1,2

Fast Track Services Consul

(SPO) Observation,
Treatment/Operation

Out Patient
Hospitalized
FMEA STEPS

7
 1. Determining Highrisk Process
Management of Emergency Patient at Sanglah
Hospital Emergency Department

Process

1 2 3

Patient come Patient get

to emergency examination and Patient get
department treated award
(Patient according to its treatment
Transfer) condition

8
 2. Potential Failure
Process Failure Mode

Treatment patient is not perfect When

Patient come to patient is moved from ambulance
emergency Wrong triage
Department

Patient get
examination and A. Resuscitation is not perfect
B. Control of the patient is not good
treated according to C. Waiting for along time to get the medical
its condition measure

Patient treatment at the ward is not

Patient get award comprehensive
treatment

9
 3. Failure Mode and the effect

Item Process Potensial Failure Potensial effect Potensial Cause/

step Mode (FM) of failure mode mecanism of
(consequences) failure
1 Patient come FM1.1. Patient 1.1.1. Patient Helped by staf who
to transfer from condition not competen
emergency ambulance is not becoming worse
department perfect
FM 1.2. Wrong Triage 1.1.2. Outcome of No guideline to do
the treatment is triage
not good or not
perfect Medical staf is not
do ing well triage
Procedure patient
is still not clear
1.1.3. Complaint Helped by medical
patient because staf who not
not handling competen
professionally

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 3. Failure Mode and the effect
Ite Process step Potensial Failure Potensial Potensial Cause/
m Mode effect of mecanism of failure
failure mode
(consequenc
e/ dampak)
2 Emergency FM 2.1. 2.1. Outcome There is no
patient have Resuscitation is and resuscitation team
examination and not perfect prognoses
treatment patient are
not have a
good result
FM 2.2. Control of 2.2. Patient Room for emergency
the patient is not condition patient and false
good become emergency are not
worse and not separated
controlled
FM. 2.3. Waiting for 2.3. Patient Waiting for a long
along time to get condition time to get the
the medical become medical result
measure worse No Critical value for
laboratory services

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 3. Failure Mode and the effect
Item Process Potensial Potensial efek of Potensial Cause/
step Failure failure mode mecanism of failure
Mode (consequences)
3 Emergency FM. 3. The 3.1. Complication No coordination
patient are treatments at happen
treated by ward are not
medical comprehensi
staff after ve 3.2. Mobilization Mobilization is not done in
arrive at patient is late the beginning and no
ward coordination between
nurses and doctors
3.3. Need a long No checklist treatment
time to find the risk used at ward
factor of the patient
3.4. Long of stay Complication happen on
patient become long treatment

3.5. The increase of Control and therapy of

the cost treatment the emergency patient
are not effective

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 4. RPN Determine
Ite Process Potensial Potensial effect of Cons Potensial Cause/ Likel Current Det RP
m step Failure Mode failure mode eque mecanism of iho design ecti N
(consequences) nce failure od control on
gaps
1 Patient FM1.1. 1.1.1. Patient 5 Helped by staff 5 staff are 4 100
come to Tranfer condition becoming who not not
emergency patient is not worse competent educate
department perfect When d
patient is
moved from
ambulance
FM 1.2. 1.1.2. Outcome of the 5 No guideline to do 5 Triage 4 100
Wrong Triage treatment is not good triage standard
or not perfect is not
determin
ed

Medical staff is 4 Staff are 3 48

not doing well not
triage educate
d
Procedure patient 3 No 3 36
is still not clear correcti
on for
Procedur
e
1.1.3. Complaint 5 Helped by 4 Staff are 3 60
patient because not medical staff who not
handling not competent educate
professionally d
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 RPN Determine
Ite Process Potensial Potensial Con Potensial Lik Current Disign De RP
m step Failure effect of seq Cause/ elo control gaps tec N
Mode failure mode uen mecanism of ho tio
(consequenc ce failure od n
e)
2 Emerge FM 2.1. 2.1. Outcome 5 There is no 5 No Resus Team 5 12
ncy Resuscitati and resuscitation Yet 5
patient on is not prognoses team
have perfect patient are
examina not have a
tion and good result
FM 2.2. 2.2. Patient 5 Room for 5 No separation 4 10
treatme
Control of condition emergency between 0
nt
the patient become patient and emergency
is not good worse and not false patient and
controlled emergency are false emergency
not separated patient

FM. 2.3. 2.3. Patient 5 Waiting for a 4 No quality 3 60

Waiting for condition long time to standard for
along time become get the radiology
to get the worse medical result services
medical
measure
5 No Critical 4 No critical value 3 60
value for result
laboratory
services 14
 RPN Determine
Item Process Potensial Potensial Co Potensial L Current design De R
step Failure effect of ns Cause/ i control gaps tec P
Mode failure mode eq mecanism of k tab N
(consequence ue failure e ilit
s) nc li y
e h
o
o
3 Emergency FM. 3. The 3.1. 5 No 4d There is no a 3 80
patient treatments Complication coordination good team work
are treated at ward are happen when treat
by medical not patient
staff after comprehen 3.2. 4 Mobilization is 3 There is no 3 36
arrive at sive Mobilization not done in the standard of
ward patient is late beginning and patient
no mobilization
coordination
between
nurses and
3.3. Need a 5 doctors
No checklist 4 algoritme patient 3 60
long time to treatment treatment is not
find the risk used at ward provided
factor of the
patient
3.4. Long of 3 Complication 3 Education and 2 18
stay patient happen on training for staff
become long treatment is minim 15
 Re-design ED Services
No Old Design New Design
1 Patient Transfer from Patient Transfer from ambulance
ambulance by not by Trained staff
competence staf
2 Triage is done by not Triage is done by triage doctor
competence staf

3 Resuscitation is performed by Resuscitatition is performed

medical staf Resus Team (SPO Resuscitation)

4 Not Triage System Applied Applied Triage 5 level system

system (SPO Triage System)
5 No Separation place Separation place emergency and
emergency and non non emergency patient
emergency patient (building)

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 Action Plan For New Design
Implementation
No Action Plan Person In Charge Time Target
1 Making Team Work for resuscitation Dr Krisna Wibawa, SpB 15 April 2012

2 Redesign triage room Wayan Suardika 30 Juni 2012

3 Making triage standard and determined Komang Santosa 20 Maret 2012

president director
4 BLS training for the staff Budiarsana 15 April 2012

5 Determining of the emergency patient Dr Agus Jayendra 10 April 2012

flow
6 Infrastructure:

a. Making Separation room for the patient Wayan Suardika 30 Juni 2012
who can walk and can not. walk
b. Medical stuff for Resus team Dr. Suta Awidya 30 Juni 2012

7 Socialization Dr. Krisna Wibawa, SpB 30 Juni 2012

8 Monitoring dan Evaluate Dr. Virgowati, Eka 30 Juni 2012

Supraptiningsih

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Changes made for supporting the
management of emergency patient

Making team work of resuscitation (Rhesus Team)

Develop triage system to increase the velocity of
emergency patient services
Determine of time target as a standard emergency patient
services
Making procedure of emergency patient services
Staff Training about how to handle emergency patient
(Training Basic Life Support, Training system triage,
Patient flow socialization)
Continuing Monitor and evaluation to increase the service
performance

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RE-DESIGN EMERGENCY ROOM
 Tim Resus
Services Responsible Doctor as Team
Leader
Anestetic Doctors Responsible in airway
and Circulation
2 Nurses : airway and circulation nurse
 Triage System

Triage System 5 Level

Category Time to Doctor

Level 1 Immediate

Level 2 10 minutes

Level 3 30 minutes

Level 4 60 minutes

Level 5 120 minutes

 Triage System

TRIAGE LEVEL
TRIAGE LEVEL

I II III IV V

Time to Immedia 10 mins 30 mins 60 mins 120

care te mins
Fractile 98% 95% 90% 85% 80%
Respons
e
Admissi 70%- 40%- 20%- 10%- 0%-10%
on Rates 90% 70% 40% 20%
 TRIAGE PROCESS

Patient dying ?
yes 1
no

Shouldn`t wait ?
no yes

How Many Resource 2

None One Many

5 4 Vital signs
abnormal
normal

3
 Patient Flow Chart
Patient come to
Emergency

Can Walk?
Yes (Pedestrian access) No (Vihicle access)

Triaged by doctor Triaged by doctor

Level 3,4,5 Level 1,2

Fast Track Consul

Medical Treatment /
Operation

Out Patient
Hospitalized
 Socialization

Matery of socialization :
Patient Flow
Triage system
Resuscitation Tim
Socialization for doctors, nurses and
other emergency staff
 Result
Bagaimana respon time
Perubahan yang terjadi
Masih krodit?
Pictures before (background) and after
FMEA

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 New Design Evaluation
Process Failure RPN OLD DESIGN RPN NEW DESIGN
Step Con Lik Det RPN Con Lik Det RPN

Ambulance Not Perfect transfer 5 5 4 100 5 4 3 60

transfer
Treatment Wrong Triage 5 5 4 100 5 4 3 60
and
Resuscitation not by Resus 5 5 5 125 5 4 3 60
Examination
Team
of Patient
Control Of patien is No 5 5 4 100 5 3 3 60
Good

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