9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

UpgradedCathLab
StringfellowMemorialHospital
Anniston,Alabama,UnitedStates
HospitalCommunity

Aim:OpenupgradedCathLab
ProcessData
Date:01/22/2015
Step

Description

SupplyStoragereducedspace

FailureMode

Causes

Unabletofindcriticalsupplies ReducedSpace
duringprocedure

Effects
DelayedProcedure

Step

Description

PowerSourceMaynotbeabletouseplugsforallequipment

FailureMode

Causes

Maynotbeabletouseplugs
forallequipment

Notenough'red'plugs.
Delayinprocedure
Wouldoverloadcertainplugs.

Step

Description

MedicalAirSupplyBoxLocationisunsafe

Effects

FailureMode

Causes

Effects

Triphazard.

Boxnotmovedwith
renovation.

Interruptionofoxygen&
suction.

Step

Description

Newdocumentationsystem

FailureMode

Causes

Effects

Staffunabletousenew
systemorslow.Unableto
accessinfofromprevious
system.

Unfamiliarwithsystem.

Inaccuratedocumentation.
Physiciansupsetwithdelay.

FailureMode

Causes

Effects

EquipmentFailure

NewanduntestedStaff
unfamiliarwithequipment

Unabletocomplete
procedure

FailureMode

Causes

Effects

NewequipmentforCathLab
staffnotfamiliarandmay
notuseitproperly.Itisa
regulatoryrequirement.May
needspecialequipmentor
codesonotmayavailable.

Newequipment.

Equipmentnotused.

Step

Description

EquipmentFailure

Step

Description

Capnography

Nasalcannulaisdifferent
thanwhatiscurrentlyused.

Unabletousecapnograpy.

Step

Description

Temperature&Humidity

FailureMode

Causes

Effects

Equipmentincreasestemp.
Increasedhumidity.

Equipment

Equipmentmightoverheat
couldshutdownCathLab.
Humiditymightincreaserisk
ofinfection.

Occ Det Sev RPN Actions

10

10

100 Lookforstoragespacein
otherareas.PerKen
storageareasmustbe
monitoredfortempand
humidity.Knowwhich
suppliesdon'tneedtohave
temp/humcontrol.

Occ Det Sev RPN Actions

5

280 Testpriortoopening.

Occ Det Sev RPN Actions

10

10

800 DiscusswithPlantOpsto
haveitrelocated.Or
redesignbox.PerKenwant
togetthetableinfirstand
thenseeiflocation/design
needstobechanged.

Occ Det Sev RPN Actions

10

10

200 Keepa'host'computerwill
ptinformationfromprevious
system.Inaccurate
documentationcanbe
amended.

Occ Det Sev RPN Actions

5

10

50 Testequipmentbefore
procedures.StaffEducation
abouthowtotroubleshoot
theequipment.

Occ Det Sev RPN Actions

10

10

200 Mgrtoreviewrequirements.
Stafftrainingbeforemoveto
renovatedCathLab.

10

250 Wehave10instock.
Carefusionrepshouldsupply
moreasneeded.

Occ Det Sev RPN Actions

10

10

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19031&ScenarioId=21045&Type=1

800 DiscusswithPlantOps
Directortoseeifdesignhas
beenchanged.PerKen,
MechanicalRoomsize

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
increasedandcantakean
higherheatload.Willneed
tobetestedandadjusted
aftercompletionof
renovation.

Step

Description

ScrubSink

FailureMode

Causes

Effects

Limitedspacemakesproper
scrubbingdifficult.

Designspaceissue.

Improperscrubbing
increasedinfectionrisk.
Physiciandissatisfaction.

Watertempnothotenough

Design.

Physiciandissatisfaction.
Increasedriskofinfection.

FailureMode

Causes

Effects

Notenoughpressure

Design

Increasedinfectionrisk

Step

Description

PositiveAirPressure

Step

Description

10

Lengthoftimeittakestomove

FailureMode

Causes

Effects

Needtohaveatleast12
hourswithnoprocedures.

Emergencyatotherfacility.

Needtodoallcathshere.

FailureMode

Causes

Effects

Sizeofworkspaceslightly
decrease

Designofroom

Step

Description

11

WorkSpace

Description

12

Installationofunneededequipment

Step

Description

13

Dooronright(goingin)warpedtoomuchspaceatbottom

FailureMode

Causes

Effects

Toomuchspaceatbottom

Doorwarped

Affectpositivepressure
environment

FailureMode

Causes

Effects

Equipmentnotavailable

Wirescutduringconstruction Unabletoperformultrasound
ofcoronaryarteries.

Description

14

IVUSnotoperable

10

350 Redesign.NewSink.Per
Ken,sinkwillbeinsame
locationbutwillbelarger.

10

10

500 DiscusswithPlantOps.
Redesign.PerKennewhot
watertankbeinginstalled.

Occ Det Sev RPN Actions

5

10

250 TalkwithPlantOps

Occ Det Sev RPN Actions

3

10

210 First,moveenoughsupplies
foranemergencycath.Plan
tohavenoactivityforat
least12hoursnotifyER
andcardiologists.

Occ Det Sev RPN Actions

10

Step

Step

Occ Det Sev RPN Actions

10

500 Organizationadded
cabinets.Movesome
equipmenti.e.balloon
pump.

Occ Det Sev RPN Actions

10

70 Repairorreplacedoor

Occ Det Sev RPN Actions

5

10

250 TrytohaveIVUSrepaired
beforemove.Ifthatisn't
possibleinformcardiologists
thatitisn'tavailable.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

4810

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=19031&ScenarioId=21045&Type=1

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