9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofOutpatientfallsriskassessment
LittletonAdventistHospital
Littleton,Colorado,UnitedStates
HospitalCommunity

Aim:Todecreaseoutpatientfallsby50%in12months.
ProcessData
Date:03/30/2008
Step

Description

Outpatiententersfacility

Step

Description

Outpatientcheckinatvolunteercheckin

FailureMode

Causes

Volunteerscannotdetermine Noassessmenttoolor
ifpatientsareatrisktofall
educationforvolunteers

Effects
Nofallriskassignedto
outpatients

Step

Description

OPfillsoutregistrationformandvolunteersignstheptinfor
test/procedure

Step

Description

Patientsitsinthewaitingareaandwaitstobecalledbyadmissions

Step

Description

Admissionscallspatientuptodesktoobtainptinfo

FailureMode

Causes

Effects

Noinfotakenfrompatient
specificallyregardingfalls
risk

Notooloreducationtostaff

Patientsriskforfalling
unrecognized

Step

Description

Patientmeetswtihadmissionspersonal

FailureMode

Causes

Effects

Noassessmentoffallsrisk

Notoolforriskassessment
nostafftraining

Allpatientsgounassessed

Step

Description

Patientleavestodesignatedtestingarea

FailureMode

Causes

Effects

Patientnotidentifiedasa
fallsrisk

Nofallsrisktooldeveloped
noeducationofoutpatient
staff

Highriskpatientsnot
identifiedasafallspotential

Occ Det Sev RPN Actions

10

450 Inacteducationonfallrisk

Occ Det Sev RPN Actions

10

250 Inactfallsrisktooland
educationforstaff

Occ Det Sev RPN Actions

10

250 Inactafallsriskassessment
andeducationofstaff

Occ Det Sev RPN Actions

10

250 Inactfallsriskassessment

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

1200

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=6274&ScenarioId=7430&Type=1

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