9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

CopyofPreventingCLABSIs
TexasTechUniversityHealthSciencesCenter
Lubbock,Texas,UnitedStates
HospitalCommunity

Aim:Reducethenumberofcentrallineassociatedbloodstreaminfectionsby50percentin1year.
ProcessData
Date:04/19/2013
Step

Description

Educatingstaffaboutcentrallineassociatedbloodstreaminfections

FailureMode

Causes

Effects

Staffarenotinformedon
properprocedurewhen
workingwithcentrallines

Step

Description

Priortoinserstionofcentrallinespatientsandfamilieswillbe
educatedonpreventionofCLABSIs

FailureMode

Causes

Effects

Languagebarrier,learning
disability,familymembers
notpresent,poor
communicationbetween
medicalstaffandpatient.

Description

Performhandhygienebeforecatheterinsertionormanipulation.

FailureMode

Causes

Effects

Staffandpatientsnot
performingproperhand
washingtechniquespriorto
handleingcentrallines.

Notenoughtime.
Attitude.

Infectiontopatient

Step

Description

Useastandardizedprotocoltodisinfectcatheterhubsbefore
accessingthelines.

FailureMode

Causes

Effects

Staffand/orpatientsdonot
vigorouslyscrubthehub
usingalcoholfor15seconds
priortoaccessingline.

Notenoughtime
Lazy

Infectionofline

Step

Description

Changecentrallinedressingevery7days,ifsaturated,orsite
exposed.

FailureMode

Causes

Effects

Dressingnotbeingchanged
inatimelymannerorwhen
saturatedorsiteexposed.

Incorrectdates
Notcheckingsitefrequently

Possibleinfection

Step

Description

Evaluateallcentralvenouscathetersroutinely.
Causes

Centrallinesarenotbeing
evaluatedbystaffona
routinebasis.

Effects

10

160 Educationwilloccurwithall
newhiresandannuallyasa
apartofbedside
competencies.

Occ Det Sev RPN Actions

5

Step

FailureMode

Occ Det Sev RPN Actions

160 Provideinterpretative
services.Askpatientand
familypreferredlearning
style.Communicateusing
languageeasilyunderstood
bypatientsandfamilies.

Occ Det Sev RPN Actions

4

10

160 Continuousobservation,
ongoingeducationand
counselingasneeded.

Occ Det Sev RPN Actions

5

10

200 Educationonproper
techniqueondisinfecting
catheterhubs.

Occ Det Sev RPN Actions

4

72 Monitordressingevery4
hoursduringshift.Maintain
accuratelogonprevious
dressingchanges.Change
dressingimmediatelyif
saturatedorsiteexposed.

Occ Det Sev RPN Actions

5

140 Formacommitteeto
evaluateallcentrallineson
unit.Auditchartstomake
suretimelydressingchanges
occur.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

892

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

10=VerylikelyitWILLNOTbedetected

Sev: Severity(110)

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=15328&ScenarioId=17493&Type=1

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9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

RPN:RiskPriorityNumber(OccDetSev)

Annotation
None

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=15328&ScenarioId=17493&Type=1

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