9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofPatientIdentification
UnitedStates
HospitalCommunity

Aim:PatientIdentification
ProcessData
Date:04/14/2011
Step

Description

Patientrecievesarmbandatadmission

FailureMode

Causes

armbandnotplacedon
patientuponarrivaltoED

multiplepatientstotriage
ptsinroomsandwaiting
andcheckinso
roomwithoutarmbands
armbands/facesheetsprinted
andplacedondesk

Effects

Occ Det Sev RPN Actions

9

504 placedarmbandonpatient
uponarrival

patientgivenwrongarmband didnotreadarmbandand
byadmissionclerk
askpatienttheirname

patientismislabeled

324

patienttakendirectlytoroom noarmband
withoutcheckinginwith
admissions

treament/teststartedona
patientwithoutanyone
checkingtomakesurethey
havethecorrectpatient

240

patientdoesnothave
anywaytoverifytheir
identity

can'taccuratleyidpt

48

didnotbringphotoid

patientarrivesbyambulance placedinroompriorto
recievingarmband
Step

Description

Patientseenbynurse/labtech/xr/respfortreatmentortest

FailureMode

Causes

Effects

Occ Det Sev RPN Actions

employeedoesnotaskwhat askthepatientonetimewhat
thepatientsnameisupon
theirnameisanddonot
meetingthepatienteach
repeatduringvisit
time

315

identifypatientbasedon
roomnumber

10

810

30

patienttakenfor
test/treatmentwithoutan
armband

inahurrytocompletetask

Step

Description

Patienthasanorderfortest/treatment

FailureMode

Causes

nonameonorder

unsureofwhotheorderis
reallyfor

Effects

63

orderplacedonwrongchart

wrongpatientrecieves
treatment

200

wrongpatientstickerplaced
onorder

wrongpatientreceivesorder

162

10

10

600

chartdoesnotfollowinptsto
XRorResp
Step

Description

Employeeverfiesrightpatient/rightorder/test/treatment

FailureMode

Causes

donotreallycheckthe
armbandwithwrittenorder
orrequest

patient/testmismatch

Effects

donottakeMARorchartinto mederror
room
donotaskpatienttostate
theirname

askleadingquestion

Step

Description

Specimencollectedfrompatient

FailureMode

Causes

donotlabelinfrontofpatient
placethewrongstickeron
specimen

wrongpatientreceives
resultsfortest

Effects

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

9

360

10

540

10

420

Occ Det Sev RPN Actions

9

10

810

324

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=12400&ScenarioId=14157&Type=1

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

Step

Description

specimensenttolab/resp

FailureMode

Causes

labacceptsunlabeled
specimen

trustsstafftotellthemwho
thespecimentbelongsto

240

labmislabelsspecimen

doesnotcheckthelabelon
thespecimenwiththe
request

10

360

Step

Description

resultstochart/mdoffice

Effects

FailureMode

Causes

wronginformationgivento
physician

wrongtreamentorderedfor
patient

140

testresultplacedonwrong
chart

didnotlookatstickeron
charttomakesureplacing
resultincorrectplace

448

resultsplacedonwrongchart nostickersonchart
ined
paperwork/onlyroom
numberonoutsideofchart

252

Step

Description

treatmentorderedbasedonresultsofspecimen

Effects

Occ Det Sev RPN Actions

FailureMode

Causes

Effects

incorrectresultsgivento
physician

patientmislabeling
wronginformationtochart
wronginformationentered
intocomputer

delayincorrecttreatment

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

6

270

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

7466

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=12400&ScenarioId=14157&Type=1

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