9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

AMICare:DoortoBalloonin120Minutes
MethodistHospitalNorth
Memphis,Tennessee,UnitedStates
HospitalCommunity

Aim:IncaringforemergentAMIpatients,by12/15/05removeallbarrierstoachievingreperfusionwithin120minutesfromarrivaltohospitalat
least95%ofthetime.

ProcessData
Date:12/04/2005
Step

Description

PatientprocessedthroughRapidTriage

FailureMode

Causes

Delayinrapidtriage

BackupinED
DelayininitiationofChest
Insufficientstaffing
PainTrackI
Urgencyofcasenotidentified

Effects

Delayintreatmentwith
arrivalbyambulance

CommunicationbetweenEMT Delayintreatment
andED

Step

Description

12LeadEKGdonewithin2minutesandgiventoEDMD

FailureMode

Causes

12LeadEKGnotdone

Equipmentnotinareano
Delayindiagnosisdelayin
oneavailabletoperform
treatment
testequipmentnotworking.

PendingEMTarrivaltoreview Nowaytotransmitfrom
remoteEKG
ambulance
Step

Description

ChestPainTrackIfullyinitiatedwithin10minutes

Effects

Delayindiagnosis

Occ Det Sev RPN Actions

10 Ensureadequatestaffingand
propertrainingtoensure
thatpotentialAMIpatients
arerecognizedandtheteam
knowswhatstepstotake.
100 Improvecommunications
betweenEDandEMT

Occ Det Sev RPN Actions

1

6 Ensureequipmentinworking
orderwithtrainedstaff
placeforrapidaccessibility.

256 LifeNetsystemtoallow
transmissionfromEMTtoED

FailureMode

Causes

Effects

ChestPainTrackInot
initiated

Staffnottrainedtoinitiate
nocopieshandycasenot
recognizedaspotentialAMI
nurseremiss.

Treatmentdelayedwith
potentialharmtopatien

8 Propertrainingand
resourcesfollowuponany
missedopportunities.

ChestPainTrackIinitiated
incorrectly

Impropertrainingor
experience

Delayininitiatingtreatment

12 Ensurealltriagenursesare
properlytrained.

Notallmedicationsnot
readilyavailable

Stocknotreplenished

Delayintreatment

140 ProvideAMIMedicationKitto
ensureallnecessarydrugs
andtesttubeswithineasy
onetouchaccess.

Delays

70 HaveallsuppliesinAMIKit

Delayinassemblinglabtubes Logisticsofgathering
andorders
supplies
Step

Description

CompareEKGtoanypreviousstudiesonfile

FailureMode

Causes

Effects

delayinpullingprevious
studies

MUSEinanotherareaofED

Delayindiagnosis

Step

Description

DiagnosisofAMImade

FailureMode

Causes

DiagnosisofAMInotmade
immediately

Physicianerrorunavailability Delayintreatment
ofalltestresultstoverify
potentiallyfatalerror
atypicalpresenting
symptoms

Step

Description

CathTeam&Cardiologistallsummonedatonce

Effects

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

5

15 RelocatedMUSEtorapid
triagearea

Occ Det Sev RPN Actions

2

10

FailureMode

Causes

Effects

Toomuchtimespenton
coordinatingCathTeamand
Cardiologist

Logisticsof4phonecalls
awaiting4responses

Delayingettingcathstarted

Cardiologistdoesn'trealize
urgencyofneed

Communicationweakness
unclearexpectations

Delayinprocedureand
potentialincreaseincardiac
damage

80 Ensurerapiddiagnostic
inputassessanyfailures
BIoNetpointofcaretesting
systemtospeedlabresults

Occ Det Sev RPN Actions

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=1958&ScenarioId=2461&Type=1

96 Batchpagerandcascade
communicationsto
acknowledgewhenenroute.
RemoveHouseSupervisor
fromcommunicationloop
432 CodeSTEMIScriptingand
communicationfeedback

1/2

9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

Step

Description

Cathteam/cardiologistreadyforcase

FailureMode

Causes

Effects

Delayintraffictraveltime
fromcartoCathLab

Trafficproblemsphysician
andAssociateparkingon
othersideofhospitalno
convenientspotscloseto
entrance

Delayintreatment

Step

Description

PatienttransferredfromEDwithin30minutesofarrival

FailureMode

Causes

Patientnottransferredwithin DelayinCathTeamarrival
30minutes
delayinPCIMDarrivalcath
labnotreadynoone
availabletoassistEDRNin
transport
Step

Description

Balloonsuccessfullyinsertedwithin120minutes

Effects
Delayinprocedure

FailureMode

Causes

Effects

Balloonnotinsertedwithin
120minutes

Latearrivaltocathlab
problemswithpatient
reperfusion

Increasedriskofcardiac
damage

Occ Det Sev RPN Actions

10

60 Liftanyparkingrestrictions
forCathTeam/Cardiologist

Occ Det Sev RPN Actions

8

128 Processchangetohave2
preparelabwhile3rdgoes
toassistwithpatient
transport

Occ Det Sev RPN Actions

8

10

320 Removeallcontrollable
barriersandprovide
feedbackofperformance

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1733

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=1958&ScenarioId=2461&Type=1

2/2