9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

PainManagementImprovementProject
MercerCountyCommunityHospital
coldwater,Ohio,UnitedStates
HospitalCommunity

Aim:ImproveourHCAPSscoresrelatedtoPainManagement.
ReduceourRPNforPainManagement
ProcessData
Date:03/05/2015
Step

Description

Onadmission,Patientisassessedforpain

FailureMode

Causes

Assessmentisnotcompleted nurseforgets
onadmission

Effects
Patientspainisnot
effectivelycontrolled

Patientunableto
communicate

RNdoesnotusethenon
verbalpainassessment
scoringtooltodetermine
painlevel.

Step

Description

AssessAcceptableLevelofPainonAdmissionTriageform

FailureMode

Causes

Effects

Whenpatientdeniespainon
admission,thetriageform
willnotallowtheRNto
documentacceptablelevelof
pain.

ComputerizedDocumentation
systemdoesnotallowusto
completelyassesspainwhen
patientdeniespain.

Wedonotknowon
admissionwhatthe
acceptablelevelofpainisfor
thepatient

PatientandRNdonot
understandwhatthe
acceptablelevelofpainscore
meansorrangeofnumbers
isappropriate

RNdoesnoteducatethe
patientonwhatan
acceptablelevelofpain
shouldbesothatthepatient
understands.

64 Continuecurrentprocess.
Likelihoodofoccurrenceis
low.

256 1.EducateRNsaboutthe
ViewFlaccScaleandWong
BakerScaleonthetriage
sectionofM2.
Openupthebulletedscales
andcompleteasneeded.
PlacetriggerontheM2
CheatSheet(yellowpaper)
toremindtousetheFLACC
andWongBakerScales.
Askfamilyorusefamily
statementsinyour
assessment.

10

10

100 1.EducateRNsaboutthe
ViewFlaccScaleandWong
BakerScalesfornonverbal
childrenandcognitively
impairedpatients.
2.Asteriskplacedunderthe
triageformtoremindtouse
theViewFlaccScaleif
patientunablecommunicate.

Occ Det Sev RPN Actions

10

90 1.EducatetheRNstocheck
admitstopainanddocument
deniespainatthistimein
thelocationbox.Thentype
inacceptablelevelofpain.
2.RemoveDeniesPain
checkbox.

LackofknowledgebytheRN Patient'spainisnotunder
inhowtocommunicatetothe control.
patientwhattheiracceptable
levelofpainisandhowitis
chosen.

54 1.EducateRNsinhowto
assessforacceptablelevel
ofpain.
2.EducateRNsinexplaining
ittothepatientintermsthe
patientwillunderstand.
3.Example"Whenyouare
athomeanddeveloppain,
atwhatnumber010doyou
takesomethingforpain?"

LackofknowledgeoftheRN
inunderstandingwhat
acceptablelevelofpainis
andhowtoassessandhow
toexplaintothepatient.

10

80 1.EducatetheRNinhowto
explaintheacceptablelevel
ofpaininwordsthepatient
understands.

10

90 1.EducatetheRNsonthe
nonverbaltools,FLACCand
WongBakerScales
2.Educateonacceptable
levelofpainandhowto
assessthisinformation.
3.EducateRNstoexplainin
patient'stermswhat
acceptablelevelofpainis.

Painisnotcontrolled.

RNsnotusingthenonverbal
assessmenttooltodetermine
whatacceptablelevelofpain
wouldbeforthispatient.

Step

Description

CommunicationfromATRNtoStaffRNPainscoreandacceptable
levelofpainscore

FailureMode

Occ Det Sev RPN Actions

Causes

Effects

Occ Det Sev RPN Actions

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StaffRNbusyandnohand
offcompletedfromATto
staffRN

ATRNmovedontoanother
admissionorwenton
transferorontothenext
task.
StaffRNwenttolunchor
busywithtasksinanother
room,ATRNforgetstogive
report.

Painscoreandacceptable
levelofpainnotapriorityor
focus.Thepatienthasno
painrelief.

25 1.EducateRNthehandoff
fromATtoStaffRNisa
priorityandimportantstepin
completingtheadmission.
2.Add"reportgivento
primaryRN"onthe
AdmissionChecklist.
3.DefinewhattheATRN
roleforcompletingpatient
admission.
4.Developahandoff
processwhenAThanding
overthecaretotheprimary
RN.

Whenthepatientisnot
Painassessmentisnota
StaffRNdoesn'tknowpain
experiencingpain,theATRN priorityingivingreportwhen assessmentoracceptable
doesnotcommunicatetothe theydon'thavepain.
levelofpain.
staffRNaboutpainor
acceptablelevelofpain.

56 Developahandoffprocess
forATtoStaffRNthat
includespainassessment
andacceptablelevelofpain
evenifzeropainornot
havingpainonadmission.
2.ATRNneedstodocument
onthebackofthepinkflow
sheetacceptablelevelof
pain.
3.ATRNtakethepinkflow
sheetintotheroomduring
admission.EducateRNabout
thisprocess.
4.DocumentontheWHite
Boardtheacceptablelevelof
pain.

ATRNgettingpulledto
transfer,anotheradmission
oremergencysituationand
nocommunicationgiven

ATgetspulledaspartoftheir StaffRNdoesn'tknowif
jobdescription
patientinpainortheir
acceptablelevelofpain.

Step

Description

ATRNorstaffRNdocumentonWhiteBoardtheacceptablelevelof
painscore

144 AswedeveloptheAThand
offchecklist,includelevels
ofcompletion.
Thechecklistwillprioritize
whatneedstobecompleted
firstandsubsequently
throughtheadmission.

FailureMode

Causes

Effects

ATRNforgetstowriteiton
thewhiteboard

Notapriority

Unawareofthepaingoalfor
thepatientandnurse

128 1.AddtoAdmission
Checklist"PainGoal
documentedonwhite
board".

ATRNgetsinterruptedand
pulledawayfromthe
patient'sadmission

ThatistheroleoftheATRN

PainGoaldoesnotget
writtenonthewhiteboard

112 Handoffprocesstoinclude
writingthepaingoalonthe
whiteboard.Developthison
backsideofadmission
checklist.

Thenumberforacceptable
levelofpainisnot
reassessedordocumented
onwhiteboardaccordingto
policy

Becausenotpriority.RN
NotvisibleforpatientorRN
doesn'treassessifnothaving
pain.Lackofknowledgeof
theRNknowinghowto
assessacceptablelevelof
painandwhyitisimportant.

10

10

200 1.UpdateAdmissionPolicy
toincludedocumentingPain
Goalonwhiteboard.
2.Includeinpolicywhen
assessingpainlevelto
confirm/reassesspaingoal
everyshift.
3.EducatetheRNinthe
aboveduringpain
assessment.

Step

Description

ATRNorstaffRNdocumentonthenursingflowsheet
Effects

Occ Det Sev RPN Actions

FailureMode

Causes

ATRNforgetstodocument
theacceptablelevelofpain
ontheflowsheet

Notapriority,notapolicy,
StaffRNnotawareof
ATgetspulledaway.Pain
acceptableofpainandthe
levelzerosoacceptablelevel patient'spaingoalisnotmet
wasnotassessed.

64 Addtothechecklistfor
admission"document
acceptableofpainondaily
flowsheet.

ATRNispulledawayfrom
theadmissionandcannot
completethedocumentation
ontheflowsheet

ATrolegetspulled.Nota
goodhandoff

128 1.Checklistincludespink
flowsheet,whiteboard,
scales,openupforpaingoal
ifnopain.
2.Thehandofftoolwith
prioritizedchecklist.Triage
completedfirstwith
acceptablelevelofpain
documented.

Theflowsheetiskeptwith
thechartatthedeskandis
notwiththeATRNduring
assessment

Wehavepaperchartingand Notdocumentedandpainnot
portionsofthechartarewith controlled.
theATandtheotherportion
isatthedesk.

10

80 1.Computerized
documentationsystemwill
help.
2.Checklistforadmission
3.Includedinhandoff
communication

64 Addtocheckliston
admission
Updatepolicy

Paingoalnotcommunicated
totheRNnotonthedaily
flowsheetpatientpainnot
undercontrol

TheStaffnurseforgetsto
Notapriority,Patientnot
Paingoalnotcharted
documentontheflowsheetif havingpain,neveraddressed
missedbytheATRNor
accordingtopolicy.
Step

Occ Det Sev RPN Actions

Description

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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
Painonadmission,ATRNorStaffRNaddressesthepainrightaway
duringadmissionprocess

FailureMode

Causes

Effects

Therearenoordersforpain
medicationgivenforEDor
Directadmits

Patientwasnothavingpain
inEDorofficeandpain
beganafterarrivaltofloor.
Painnotapriorityfor
physicians.

Patientsitsinpain

10

560 1.Ordersetsshouldinclude
Painasasectiononallpre
printedorders.
2.UpdateIVandPOPain
ordersets1460aand1460b
toincludepatient'spaingoal
andassessmentinformation
3.Physicianeducationon
painscoresandordersets
andneedtofocusonpain
controlforthepatient.

Bothnursesareinterrupted
withanemergencyorother
patientcareissue

Emergentsituationbecomes
priorityontheunit.

Patientremainsinpainuntil
anRNcanaddressthe
situation.

10

180 1.ADmissionChecklistwill
helpifATisatemergency
andthenhastogoon
transfer.THechecklistwill
identifywhatneedstobe
assessedorthestaffnurse
willneedtoaddressallthe
admissiontofindoutwhat
needsdone.
2.DelegatetoanotherRN
notintheemergency
situationtohelpoutwiththe
painissues.
3.Delegatetoanursing
assistanttoperformnon
pharmacological
interventionstohelppriorto
medicationsreceivedfrom
physicianorders.

Painmedicationordersare
notprocessedtimelybythe
unitsecretaryornightshift
RNfaxingtheordersto
pharmacy

Thecurrentprocessfororder Painremainsinpain.
entryisnotstreamlinedor
efficient.Severalstaff
involvedwiththeprocess.No
24hourpharmacyavailable.

10

490 1.24hourpharmacistto
processordersintimely
manner.TobeginSummer
2015
2.Newelectronic
documentationwill
streamlinetheordersand
processtimely.
3.Increasedawarenessand
educationtotheRNswill
bringthisaspriority.

Pharmacydoesnotprofile
thepainmedicationsina
timelymanner

No24hourpharmacistand
Patientremainsinpain.
pharmacyistryingtoprocess
everythingfromthenight
beforeoritisn'tprofileduntil
thenextday.

10

400 24hourpharmacySummer
2015
IncreasedRNawarenessand
education

OneRNworkingonaside
andno24/7pharmacistto
profile.TheoneRNhasto
waitforanotherRNto
witnessanoverridetopull
thepainmedication

Censusdecreased,leaving
Patientremainsinpain
minimumstaffinganddoesn't
accountformedication
witnessing.

10

10

10 1000 1.Pharmacytogiveideas
forpeoplewhocanwaste.
2.Keepinlockednarcotic
boxincupboarduntil
someoneavailableorshift
change.
3.NotifyNSandATwhois
receivingnarcoticstobe
awarewhentoroundagain.

10

10

10 1000 1.25HourPharmacycoming
Summer2015

Nopharmacistavailableafter No24hourpharmacistto
7pmonweekdaysand4pm
profilemedications.
onweekendsrequiringall
newmedicationstouse
witnesstooverride.

Step

Description

Ifpainpresent,performpharmacologicinterventions

1.RNshavetooverridemed
dispensenotusingallofthe
safetyfeaturesforthe
pateient
2.RNhastowaitforan
overridetodispence
medication,patientwaitsin
pain

FailureMode

Causes

24hourpharmacynot
availableandrequires
overridewith2RNsfor
witness

Increasedriskformedication Patientremiansinpain
dispenseerrors.
SecondRNnotavailableto
witnessatthattime.

Effects

Ifpartialdosetobegiven,
SecondRNnotavailableto
requires2RNstobepresent wasteatthattime.
towaste

PainmedicationorderedisIV Patientadirectadmitfrom
andnoIVaccesson
physicainoffice.
admission
PatienttohaveIVstarted

Patientremainsinpain.

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

8

512 1.24HourPharmacycoming
summer2015
2.NSorATRNnotifiedand
neededtooverride.
3.Delegatetonursing
assisanttoperformnon
pharmacological
interventionsuntil
pharmacological
interventionsaremade
4.

384 1.Pharmacytogiveideas
forpeoplewhocanwaste.
2.Keepinlockednarcotic
boxincupboarduntil
someoneavailableorshift
changetowastemedication.
3.NotifyNSandATwhois
receivingnarcoticstobe
awarewhentoroundagain.

256 1.Painapriorityon
admissionchecklistand
shouldbeassessed

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andremaininpain.
RNStaffunabletoobtainIV
access.
Physicaincalledtoobtain
orderforPOpainmedication
andRNnotrecievingorders
ornoreturnedcallfrom
physicianaft

immedialtyuponarrivalto
floor.
2.NSandATRNmade
awareofnoIVaccessand
attempttoplaceline.
3.Nonpharmacological
interventionsattempted
whileIVlinebeingplacedor
whilecallingphysicainforPO
orders.

Painmedicationorderedis
POandpatientisunableto
swalloworNPO

RNtocontactphysicainto
Patientremainsinpain.
obtainIV,IM,topical,orSL
painmedicationorderor
clarifyifNPO,OKtogive
medications.Physiciannot
returningpagesorcallsfor
painmedsintimelymanner.

256 1.EducatetheRNtocontact
thephysicianandgetmeds
inalternativeforms.
2.EducateRNsthisisas
importantasBP,Blood
Glucose,otheremergent
situations.
3.Usecriticallabvalue
processwhenphysiciansnot
callingbackwithin15
minutesafterpaging.
4.Educatetophysicians
abouturgencyofpainsimilar
tocriticallabvalueor
changeinvitalsigns,etc.at
ServiceOneandother
physiciancommittees.

Patientisnauseatedand
medicationisoralthatis
orderedbyphysician

Patient'sconditionchanged
Physiciandidn'torder
alternativeroutesforpain
meds
Antiemeticwasn'tordered
onadmission
Nauseaoccursbecauseof
oralpainmedicationsgiven.

384 1.Ordertoincludeanti
emeticforpainmedication
becauseitisacommonside
effectofpainmedication.
2.Ordertoinclude
alternativemedicationroutes
forpainmedication.
3.Staffandpatienteducated
onsideeffectscommonwith
painmedications.

TheRNchoosesnotto
medicateaccordingto
patient'spainratingbasedon
personalbias

1.LackofknowledgetoRN
Patientremainsinpain.
aboutpaincontrol.
2.Physicainsnotbeing
contactedforalternativepain
medications.
3.RNdoesnotplacepainas
apriorty.

10

10

600 1.Policiesupdateaboutpain
control/management.
2.IncreaseinRNawareness
andeducationaboutpain
toleranceinpateint.
3.Chartreviewandfollow
up1:1orgroupmeeting

Familystatesnonverbalor
lethargicpatientisinpain.
TheRNbelievespatientis
comfortableanddoesnot
performinterventionsthe
familywantsforthepatient.

Familyupset,unsatisfiedwith Patientremainsinpain.
patientcare.
FLACCandWongBakerpain
scalesnotusetoassess
patientspain.
Patientconditionmay
detoriorate.

10

300 1.RNtousenonverbal
assessmentscalesFLACC
andBakerWong
2.RNtolistentothefamily
inanempatheticmanner.
3.Usefamily'sinformation
asdataforassessment
documentationandspeaking
withthephysician.

10

10

200 1.WhiteBoardpolicyneeds
written.
2.EducateRNsonEBPand
researchshowinghow
informingthepatientand
familynextpainmedtime
andlastpainmedtimehelps
withtheirpaincontrol.
3.Educatingandexplaining
totheRNhowallthecare
teammemberscanhelpwith
thepatient'spain
managementplan.

Whiteboardnotupdatedwith Thereisnowhiteboard
lastpainmedgivenandtime policyexplainingwhattheRN
nextpainmeddue.
isresponsiblefor
documentingontheboard
aboutpain.
LackofknowledgewithRNs
understandingwhytheyneed
todocumentlastpainmed
andnextpainmedonwhite
board.RNsfeelitmakesthe
pat

Patientremainsinpain

Painisnotcontrolled.Patient
doesn'tfeelpartofthepain
managementprocess.Care
teamisnotawareofpain
managementplantohelp
supportthepatient'spain
goal.

Step

Description

Ifpainpresent,performnonpharmacologicinterventions

FailureMode

Causes

Effects

Lackofincorporationofnon
pharmacologicintotheplan
ofcare.Onlymedications
utilized.

Lackofknowledgewiththe
RNonalternativemeasures.
Lackofequipmentor
supplieswhendoingnon
pharmacologicalmethods.
Lackoftimetoperformthe
intervention.
Lackofstafftoperformthe
interventions.

Painremainsuncomfortable
andinpain.
Medicationsareusedmore
thantryingnon
pharmacological
interventions.

Occ Det Sev RPN Actions

9

Ittakesmoretimefromthe
RNandNAinorderto
implementthesenon

Staffingratiosandhigh
Patientremains
censusmakedifficulttofocus uncomfortableandpossibly
onthesewithalotofcall
receivingmoremedication

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81 1.EducateRNsandother
stafftoperformnon
pharmacological
interventions.
2.Laminatedcheatsheet
postedunderthewhite
boardincludingOtherThings
wecandoforyourpain.
3.PatientEducationsheeton
painandincludealternative
nonpharmacological
interventions.
4.Educatetheclinical
departmentsaboutthewhite
board,nonpharmacological
interventionsandthingsthey
couldtohelpthepatient.
5.Hourlyroundstoinclude
nonpharmacological
interventionsasweinitiatea
po
128 1.EducateRNstonotifythe
NSwhenmorestaffare
neededandexplain

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pharmacologicinterventions

lightsandpatientsneeding2 thanneeded.
caregiverstomoveor
performADLS
2.Lackofeducationtothe
nursesandnursingassistants
onnonpharmacological
interventions.
3.Lack

Patientpreferencetheydo
notwantnon
pharmacological
interventions

1.Patientdoesn'tliketobe
touchedwhentheyarein
pain.
2.Patientjustwantsthepain
medication
3.Patientnoteducatedon
hownonpharmacological
interventionscanalleviate
pain.

Equipmentnotavailableto
implementnon
pharmacologicinterventions

Supplyparlevelsmaynotbe Painisnotcontrolledwith
adequate.
nonpharmacological
Spacelimitedforsupplies
interventions.
andequipmentontheunit.
Communicationofneedof
suppliesisnotgiventothe
appropriateperson.
Theemployeedoesn'thave
empowermenttocontactthe
orderingdepartmenttoget
sup

Patientisnotcomfortable
andpainnotrelieved.
Patientreceivingmorepain
medicationthantheymay
need.

Step

Description

Reassesspatientwithin1hourafterIVmedicationandwithin2hours
afteroralmedication

FailureMode

Causes

Effects

RNbusyoremergency
situation

Lackofknowledgeand
understandingpain
assessmentisaprioritylike
BPandBloodGlucose
RNdoesnotdelegateto
anotherstaffRNtoreassess
orworkwithNAtohelpwith
reassessment.
Ourpolicyisoutdatedand
notEBP.

Patientisnotreassessedfor
pain.Painisuncontrolled.

PatientsleepingsoRNdoes
notreassesspainlevel

1.Painpolicydoesn'taddress Patientremainsinpain.
thisissue.
2.LackofknowledgetoRNs
thatsleepingdoesn'tmean
painrelief.
3.RNisafraidtowakethe
patientupaftermedication
given.

HowtheRNisscriptingabout LackofknowledgeoftheRN
theimportanceof
aboutreassessmentand
reassessmentandmeeting
acceptablelevelofpain.
acceptablelevelofpainand
notjustallowingthemto
sleep

Painisnotrelieved

LowpriorityfortheRNto
reassesspaininterventions
andeffectiveness

LackofeducationofRN

Painnotrelieved.

RNsdonotusethetimersto
remindtoreassessforpain

Lackofknowledgetohaveit Painisnotrelieved.
asaprioritytoreassess
usingthetimers.
Timersunavailable.

Step

Description

10

Ifacceptablelevelofpainisnotmetwithmedicationintervention,
lookforalternativesordered

FailureMode

Causes

Effects

situation.Tellthestoryso
theNScandeterminehow
besttohelptheunit.
2.EducateRNsandNAson
nonpharmacological
interventionsandhavecheat
sheetavailable.
3.EducateRNsbyshowing
theEBPresearchonpain
managementandhowmeds
andnonmedication
interventioncanhelp.
4.Involvethefamilyin
doingnonpharmacological
interventionswhiletheyare
visiting.
2.
5

35 1.Developapaineducation
sheettoincludenon
pharmacological
interventions
2.Cheatsheetavailablein
roomunderwhiteboard
identifyingthenon
pharmacological
interventions.

24 1.Maureentoworkwith
Materialsmanagementabout
parlevelsandfrequentnon
pharmacologicalitems
runningouttoosoon.
2.Maureentoworkwith
materialsandstaffon
empoweringstafftocontact
MaterialsManagement
directlywhensuppliesare
loworgone.
3.Improvecommunication
processesforimmediate
needsandbeyond.

Occ Det Sev RPN Actions

8

10

240 1.UpdatethePain
Managementpolicyincluding
changingthereassessment
timeframestoIVwithin30
minandPOwithin60orboth
within60.ExplaintoRNs
WITHIN.
2.EducateRNsthatpain
assessmentisapriorityand
asimportantasBPand
BloodGlucose
3.EducateRNsabout
delegatingtoanotherRNor
NAtoreassessusingscale.

128 1.Includeinpainpolicy
aboutpatientsleeping
doesn'tmeanpainis
relieved.
2.Educatepatientthatpain
willbereassessedwithin15
minutesifIVtodetermine
relieforwithinupdatedtime
frameaccordingtopolicy.

10

10

200 1.ChangethepolicytoEBP
researchfortimeframesfor
reassessment.
2.EducatetheRNonhow
reassessmenthelpswith
painmanagementand
control.

10

80 EducateRNaboutpain
reassessmentandthe
importancetohelppatient
havecontroloftheirpain.
Policytohelpgiveguidance
totheRNonreassessment.

10

10

100 1.POlicyupdated
2.EducateRNstousetimers
tohelpwithreassessment
reminders.
3.Newcalllightsystemto
helpwithpainreminders.

Occ Det Sev RPN Actions

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RNbusywithothertasksand 1.RNbusy
doesn'texploreother
2.Lackofknowledgeand
orderedoptions.
understandingofwhat
alternativesareavailalbeon
theirMARandhowtheycan
helprelievepainand
increasecomfort.
3.
Nootheralternativesare
ordered.

Patientremainsinpainand
painisnotcontrolled.

10

400 1.EducateRNson
alternativenonnarcotic
analgesicsinadditionto
narcoticsgiven.
2.DelegatetoanotherRNto
findanalternativeand
medicatethepatient.

1.PhysicianorNPdidn'tuse Thepatientremainsinpain
orderset
andpainisnotcontrolled.
2.RNdidnotusecareplan
forsuggestionsfor
alternativemedications
3.LackofresourcesforRN
togotoforsuggestions.(only
onorthocareplan)
4.Thephysiciandoesn'twant
toorderanythingelseforp

10

400 1.Includeinpolicythatif
acceptablelevelofpainnot
metwithmedication
intervention,RNistolook
foralternativesbycallingthe
physicianforalternative
medication.
2.Usenursinginterventions
suchasnon
pharmacological(ice,
warmth,positioning).
3.Midaseventwhen
physicianrefusingtoorder
alternativemedicationswhen
patientisinuncontrolled
pain.

10

400 EducateRNsonalternatives
andhowtodeterminetype
ofpain(neuropathic,acute
inflammatory,etc)
240 1.Patienteducation
pamphlets,uponadmission,
discussmultimodal.
2.Reviewourpatient
teachingmaterial.

Failuretoidentifytypeof
Lackofknowledge
painandactionofalternative
interventions.

Patientremainsinpainand
notcontrolled

Patientmayrefusetotake
otheralternativesthatare
orderedduetopatientbias
orlackofunderstanding
aboutthebenefitsof
multimodaldrugtherapy

Lackofknowledgeforpatient Patientremainsinpain

RNbiasaboutmedications
alreadygivenandadditional
medicationsarenotneeded

Lackofeducation

10

Failuretouseother
resourcestoidentifyother
alternatives.Suchas
orthopediccareplan
pharmacyconsultetc

1.Lackofeducationon
Patientremainsinpain.
currentresources
2.Pharmacyasaresourceis
notinvoledinpatientcareat
thistime.
3.Notallcareplansare
updatedwithpain
alternatives.

Thechart/MARnotavailable
duetoutilizationbyother
healthcareteammembers

1.WEusepaperchartsand
onlyonepersonatatime
canseetheMARandchart.

Patientremainsinpain
becausewecan'tusethe
MARorcharttoreviewcare.

10

10

800 NewEMRandelectronic
MARs.

DuringtheBedsideShift
Report,theRNsdonothold
eachotheraccountablefor
unacceptablepaingoals.
Theydon'tquestionwhathas
alreadybeendoneandwhat
isneededtobedonetohelp
thepatient.

1.Thereisnowhiteboard
Painisnotcontrolledalways.
policy.
Painremainsnotapriority.
2.RNpriorityandfocusis
BP,HeartRhythmsandplan
ofcare(whatdiddoctor
order,whatmedschanged,
antibioticsordered).Painnot
apriorityinthediscussion.
UnlesschestpainandNitrois
themedicationdis

10

10

100 1.Developawhiteboard
policy.
2.EducateRNtoincludePain
informationonwhiteboard
andassessmentduringBSR.
3.Whiteboardneedstobe
keptuptodateforPain
Goal,lastpainmedandnext
painmed.

Patientremainsinpain

Step

Description

11

Ifacceptablelevelofpainisnotmetwithcurrentmedications
ordered,contactphysician

FailureMode

Causes

Effects

RNsafraidofcalling
physicianforadditionalpain
medicationordersdueto
inappropriate,negative
behaviorfromthephysician

1.InexperiencedRNfearful
ofphysiciancommentsand
behavioronthephone.
2.RNsnotfamiliarwith
SBAR.
3.Lackofconfidenceand
knowledgeonhowto
respondtodifficult,angry,
frustratedcommentsfrom
physicians.
4.Lackofknowledgeabout

Patientremainsinpain.

Physiciannotreturningcalls
inatimelymanner

1.Insurgery/procedure
Patientremainsinpain.
2.Didn'tgetthepageortext
tocall.
3.RNcalledthewrongdoctor
4.RNafraidtokeeppaging
whentheydon'thearback.
5.RNsnotusingtheCritical

270 1.EducateRNaboutpain
medications(CindyLiette's
information)
2.MIDASreportforpainnot
managedandremaininghigh
levelofscores.
3.Accountabilityfornursing
careforpainmanagement.
ExplainandeducatetheRNs
aboutaccountabilityforpain
management.
360 1.Educationprogramfor
nursestoreviewcurrent
orthoplanofcare
2.Revisecareplansto
includealternativessimilar
toortho
3.Workwithpharmacyon
howtheycanbeinvolved
withpainmanagement.

Occ Det Sev RPN Actions

5

10

400 1.EducateRNaboutSBAR
andhowtousethisduring
phoneconversations.
2.Increasenurses
confidencebyhaving
supportfromupper
management.
3.EducateRNstothe
DisruptivePhysician
Behaviorpolicy.
4.EducateRNson
behavioralmanagement
duringescalating
conversations.

10

10

700 1.EducateprocessforRNs
onfloortoaskforanurseif
physicianinsurgeryto
communicatethepainissue
withSBAR.
2.Checkwithhospital
operatorforcalldataand

RNhesitantoncalling
physiciansandcauses
difficultybeingthepatient
advocate.

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Labpolicywhichincludes
PhysicianCommunication
process.
6.Phy

otherconcernsvoicedabout
missedcalls.
3.EducateRNaboutcalllist
anduseofit.Possiblyuse
onlinelistonly.Placethe
informationonlinethatis
easiertofind(icon).
4.EducateRNsonpolicies
thatsupportescalating
physicianpagingforpatient
care.
4.

BiasofphysiciansandRN
thinkingcurrentmedication
shouldbeenoughandthe
patientdoesn'tneedanything
further

1.Lackofknowledgeofpain
toleranceisdifferentfor
everyone.
2.Lackofknowledgeof
interactionsofpainmedsto
thepain.
3.Cultureofnursesand
physicianseducational
background.

RNtoobusyanddoesn't
reassessinatimelymanner
resultinginadelayof
notificationtothephysician
anddelayinmedicatingthe
patient.

Patientremainsinpain.

10

10

800 1.Educationtonursesabout
paintolerance,medication
interactions.
2.Tohelpchangeaculture,
keepingpainscoresasa
focusforallmeetings,etc.
andholdingstaffaccountable
duringchartreviews,etc.

1.Lackofknowledgeof
Patientremainsinpain
importanceofpain
management.
2.Lackofdelegatinganother
RNtohelporNAtoreassess
painscores.
3.Currentpolicytimeframes
outdatedandnotEBP
information.

10

10

300 Painpolicyupdatedwithnew
timeframesforassessment.

RNisawarephysicianis
goingtoroundinashorttime
andavoidscallingthemfor
additionalpainmedication
delayinginterventionsforthe
patient.

1.Pasthistoryofcalling
Patientremainsinpain
physiciansandtheycomment
theyareontheirwayandwill
takecareofitwhentheyget
tothehospital.
2.RNfearsnegative
responses/behaviorsfrom
thephysician.
3.Painisnotapriorityfor
bothRNandPhysician.

10

Physiciandelaysgiving
ordersbecausetheyare
goingtobemakingrounds
andwantstowaituntilthey
assessthepatientbefore
givingorders.

SameaspriorFailureMode

10

RNcallstheofficeand
physicianinwithapatient
andthephysiciandoesn'tcall
backwithinatimelymanner

Thecommunicationwasnot
clearusingSBARwiththe
officestafftorelaytothe
physician.

10

10

Patientremainsinpain

Delegatingandmakingpain
apriority.

240 1.Educatephysiciansonour
newpoliciesandRNswillbe
callingmorefrequentlywhen
painisnotcontrolled.
2.EducateRNsonthe
disruptivepolicy,useof
MIDASreportSBARand
howtorespondto
inappropriateconversations.
3.Makingapainapriority
similartoothervitalsigns.
60

800 EducateRNsonuseofSBAR
andusingspecificsonpain
management.
EducateRNonuseof
physiciancommunication
timeframeswhentocall
againifnotrespondingto
originalcall.

DuringBedsideShiftReport, Statedbeforeinanother
theoncomingRNdoesnot
FailureMode
question/challengetheRN
aboutcallingthephysician
forunacceptablepainlevels.

10

Step

Description

12

Ifacceptablelevelofpainnotmetwithnonpharmacological
interventions,tryanotherintervention

FailureMode

Causes

RNandNAdon'twanttotake
thetimetoperformnon
pharmacological
interventions.

1.RNandNAbusywithother Patientremainsinpain
patients/jobs
2.Lackofknowledgepaina
priority.
3.Lackofknowledgeofother
nonpharmacological
interventions.

Effects

RNsandNAsaretoobusy
anddonothavethetimeto
tryalternatives
RNsnotholdingeachother
accountablefortryingnon
pharmacological
interventionsduringBedside
ShiftReport.

Painmanagementisnota
priorityduringBSRandnon
pharmacological
interventionsarenot
discussed.

Patientremainsinpain.

TheRNforgetsthesenon
pharmacological
interventionsareavailable
andtheydonotknowallthe
choices.

Lackofknowledgebystaff
Patientremainsinpain
whatinterventionsavailable.

10

100

Occ Det Sev RPN Actions

10

10

64

81 Educatepainassessment
andmanagementwith
interventions(non
pharmacological)isapriority
duringBSR.

10

10

100 Educatestaffonnon
pharmacological
interventions
Developalistwithnon
pharmacological
interventionsandpostonthe
unitandclipboards.

Lackofresourcesreadily
available.

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300 1.Delegateiftoobusy
becausepainisimportant.
2.Educatepainisapriority
3.Makealistofallnon
pharmacological
interventionstheycouldtry
andmakeiteasily
accessible.
4.Includeallofthis
informationinorientation
andduringevaluation.

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Patientrefusesthe
alternativeinterventions

Lackofeducationgivento
thepatientaboutthese
alternativemeasures.

Step

Description

13

Assessmentofpaineveryfourhours

FailureMode

Causes

RNdoesnotfollowthepolicy 1.RNbusy
toreassesspaineveryfour
2.Notapriority
hours.
3.Delegationofothersnot
used

RNgetsbusyanddoesn't
assessorreassesspainina
timelymanner.

Patientremainsinpain

Effects
Patientremainsinpain

Talkedaboutduringanother
FailureMode

10

100 1.Reviewcurrentpain
managementpamplet
2.Lookatlocationof
resource
3.EducateRNsaboutthe
painmanagementresources
foreducation

Occ Det Sev RPN Actions

10

10

300 1.EducateRNsaboutpolicy
andprocedureforpain
assessment.
2.Lookatour
documentationtooltohelp
triggerpainreassessment.
3.Educatepainapriority

10

10

100 Educatestaffaboutpriority
ofpainassessmentand
sleepandhowitimpacts
healing.

12 EducateRNsaboutneedto
documentallfindings

64

PatientissleepingandtheRN Lackofeducationaboutpain
doesn'tthinktheyneedto
management
assessforpain.Thebelief
thatthepatienthasnopain
becausetheyaresleeping.

Patientremainsinpain

Patientisassessedforpain
everyfourhours,butisnot
chartedduetopatientnot
havingpain.

Lackofunderstandingof
assessmentand
documentationforquality.

Qualitydataismissing.Chart
notcomplete.

Thepatientisoffthefloorat
thetimeandtheRNdoesn't
assesstimely

Lackofeducationaboutneed Patientmaybeinpainwhen
toassesspainWITHIN4
theyleavethefloor.
hoursandcouldbebefore
the4hours.

10

RNassessespaineveryfour
hours,butdoesnotaddress
theaccetablelevelofpainto
determineifinterventionsare
neededorifpainiscontrolled
forthepatient.

Lackofknowledgeand
understandingassessingthe
paingoal/acceptablelevelof
paingivestheRNdatato
determineifpaincontrolled
ornot.

Painisnotcontrolled.

64 EducateRNsonimportance
ofassessingforpaingoal.
Includeinwhiteboard
policy.

Ifadmissioncomesinduring
thebeginningoftheshift,the
staffnursedoesnotaddress
painagainaccordingtothe
policy.

1.HandofffromATtostaff
RNdoesnotincludenext
timepainneedstobe
reassessed.
2.Painreassessmentnota
priorityuponadmission.
Otherdatamoreimportant.

Painisnotcontrolled

10

80 1.EducateATandStaffRN
whattoincludeduringhand
off.Discussedinprevious
FailureMode.
2.Painbecomespriority
fromadmissiontodischarge.

Interdisciplinaryteamdoes
notparticipatewith
assessmentor
documentationofpain.
Communicationnotgiven
aftertheyassesspaintothe
RN.

Onedepartmentisconsistent Patientremainsinpain
aboutassessing
pain(therapyPTandOT),
butothersneverdiscuss
pain.Respiratory,dietary,
socialworker,etc.

81 Educatealldisciplineson
askingaboutpain
assessmentafterintroducing
themselvesandwhothey
are.
TonotifyRNifpatienthaving
pain.

10

80 EducateRNsaboutpain
policyandneedtoreassess
every4hours.

Whenthepatientisnot
Painisnotapriorityandif
havingpain,theRNdoesnot theyaren'thavingit,why
thinkweneedtoreassessin takethetimetoassess.
fourhours.

Potentialforhavingincreased
painandinabilitytogetit
undercontrol.

50 EducatingtheRNaboutpain
assessmentandneedto
reassessWITHINthetime
framesforeffectivenessof
painmedication.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

17119

Occ: LikelihoodofOccurrence(110)
Det: LikelihoodofDetection(110)
NOTE: 1=VerylikelyitWILLbedetected

10=VerylikelyitWILLNOTbedetected

Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)

Annotation
None

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