FailureModesandEffectsAnalysis(FMEA)Tool

PreventPtFalls
LomaLinda
LomaLinda,California,UnitedStates
HospitalTeaching

Aim:Toreducethenumberofptfallsby20%bytheendof2014.
ProcessData
Date:08/12/2014
Step

Description

Patientpushescalllight

FailureMode

Causes

Effects

Patientdoesn'tpushcalllight Calllightoutofreach,patient Nobodycomestohelppatient

confusedanddoesn'tknowto totherestroom.
pushlight,tooweaktopush

Step

Description

Calllightisanswered

FailureMode

Causes

calllightisnotanswered

Staffbusydoingotherthings. Nobodyissenttohelppatient
Staffnotawareofthecall
ringing.Calllightnotworking
properly.

Step

Description

Someoneissenttorespondtopatient

Effects

FailureMode

Causes

Effects

Persondoesn'trespond
quicklyenough.

Busywithotherpatientsor
priorities

Patientusesbathroomon
theirown.

Step

Description

Nursingstaffassistspatienttothebathroom

FailureMode

Causes

Effects

Staffdropspatient

Stafflosesgrip.Staffnot
strongenoughtosupport
patientweight.Staffnot
payingattention.

Patientfalls

FailureMode

Causes

Effects

Patientfallsofftoilet

dizziness,confusion.

Patientfalls.

Step

Description

Patientusesrestroom

Step

Description

Nursingstaffhelpspatientbacktobed

FailureMode

Causes

Staffdropspatient

Effects

Occ Det Sev RPN Actions

4

64 Showpatienthowtouse
light.Havesomeone
dedicatedtorespondtocall
light.Periodicallycheckon
patient.

Occ Det Sev RPN Actions

2

32 Havemaintenanceroutinely
checklights.Alwayshave
someonetendingthecall
lightphone.

Occ Det Sev RPN Actions

4

84 Addmorestafftocoverthe
unit

Occ Det Sev RPN Actions

2

14 Bettertechniques/training.
multiplepeopletohelp
largerpatients.

Occ Det Sev RPN Actions

1

5 Closersupervisionfromstaff

Occ Det Sev RPN Actions

2

14 Patientfalls

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

10=VerylikelyitWILLNOTbedetected

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

Annotation

213

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