9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

SCG/OSCHighRiskMedications
SurgicalCenterOfGreensboro
Greensboro,NorthCarolina,UnitedStates
Other

Aim:ReduceriskofHighRiskMedicationErrors
ProcessData
Date:11/04/2009
Step

Description

ListHighriskmedsatourfacility

FailureMode

Causes

Effects

notlikelyasthislistisa
policycontainingHRMs

HRMcanhaveadverse
outcomes

Variablenegativehealth
issues

Step

Description

PurchaseHighRiskMedsinsingledosevial,ifapplicable

FailureMode

Causes

Effects

Drugcouldbeorderedinthe
wrongstrength/ornotin
singledosevial.

Patienttoreceivethewrong
dose/strengthofthedrug.

Adversenegativehealth
outcomes.

Step

Description

CheckstrengthofdrugsatDelivery

FailureMode

Causes

Humanerrorthatdrug
strength,typeofdrug,dose
ofdrugwasoverlooked
duringorderprocess.

Packaginglookssimilar.Staff Wrongstrength/doseis
isrushed/interrupted
placedindepartmentforuse.
performingduties.

Step

Description

HRM'slabeledwhenreceived

Effects

FailureMode

Causes

Effects

Pharmacynurseneglectsto
place"highalertdouble
check"stickeronincoming
medications.

Interruptions,rushing,
runningoutofStickers.

HRMnotrecognizedassuch
iflabelmissing.HRMnot
beingsegregatedfromother
medsperpolicy.Without
labelHRMmaynotbedouble
checkedasthisisa
reminder.

Step

Description

DeliveryofHRMtoDepartments

FailureMode

Causes

Effects

Thewrongdrug
maybedistributedtothe
wrongdepartment.

Wrongdrugisplacedin
wrongtotefordepartment
delivery.Rushingand
interruptions.

Employeeshavetofind
missingdrugifdeliveredto
wrongdepartment.

Step

Description

HRMindepts.areseparated&labeled.

FailureMode

Causes

HRMstickerwasremovedor
unbaggedanddrugswere
notseparatedorlabeledas
HRM.

Personnelindepartment
HRMmaybeplacedinarea
removeddrugfrombagwith withlookalikedrugandused
HighAlertstickerandnot
inadvertentlyasthatdrug.
segregatedfromotherdrugs.

Step

Description

HRMadministrationdonewithdoublecheck

FailureMode

Causes

Thedoublecheckbyself
Needtoquicklydistribute
maynotbedone.Thedouble medications,andshort
checkwithappropriatestaff staffingmayleadtonot

Effects

Effects
Notdoingtheselfcheckand
doublecheckwith
appropriatestaffmayleadto

Occ Det Sev RPN Actions

2

4 Keepassessingtheupdates
toNationallistofHighRisk
Medsinrelationtoour
formulary

Occ Det Sev RPN Actions

7

10

490 Doublecheckdrugorder
whenordered.OrderasSDV
whenapplicable.Double
checkdrugstrengthwhen
received.
Doublecheckdrugwhen
administering.

Occ Det Sev RPN Actions

3

10

210 Reviewdrugordersfor
accuracy,especially
strength/doseofhighrisk
meds.
ReviewondeliveryallHRMs
forstrengthanddose.

Occ Det Sev RPN Actions

2

10

160 Doublecheckingdrugs
deliveredandmakingsure
"highalertdoublecheck"
stickersareplaced
appropriatelyonallHRM.

Occ Det Sev RPN Actions

5

10

450 Payingattentionto
distributionofHRMto
appropriatedepartments.
Remindingstafftodouble
checkHighalertstickered
drugs.

Occ Det Sev RPN Actions

3

10

240 DoubleCheckingofStorage
ofalldrugssotheyare
properlyseparatedand
stored.

Occ Det Sev RPN Actions

3

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9683&ScenarioId=11215&Type=1

10

150 NeveradministerHRM
withoutthedoublecheck
methodduetoincreasedrisk

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

maynotbedone.

goingthroughthe
appropriatesteps.

administrationofaharmful
orfataldrugdosingorwrong
drug.

Step

Description

MultiDosevialInsulinrequiresdoublecheckwithanothernurse

FailureMode

Causes

Theinsulindosemayrequire
immediateadministrationand
thereforeincreasetheriskof
errorandomittingthedouble
check.

Rushingtoadministerdoseto Effectofwrongdrug/wrong
preventdeteriorationof
dosemaybecriticalinsome
statusofpatient,maycreate cases.
forgettingdoublecheck.

Step

Description

HeparinkeptinPharmacytillordered

Effects

FailureMode

Causes

Effects

Heparinmayinadvertantlybe
placedinanother
department'stotefor
deliveryratherthanbeing
keptinPharmacy.

Pharmacynurserushingor
anotherindividualwhois
undertakingthatjobandnot
beingcarefulwithproper
handlingofHRMs.

Heparininlargerdosethan
100units/ml.being
inadvertentlyplacedand
usedinanotherdepartment.

Step

Description

10

HeparinorderssenttoPharmacy

FailureMode

Causes

Heparinordersnotsentto
Thepreopordernotsentto
pharmacywillberetrievedin pharmacyinatimelymanner
panicmodeandthedoseor orlost.
drugmayhaveanincreased
riskoferrorin
administration.

Step

Description

11

OrderbaggedasHRMwithpatientorderinside

Effects
Thepanicinfollowingallthe
appropriatestepstoobtain
properdrug/dosetoproper
patientwilbeatrisk.

FailureMode

Causes

Effects

Thepatientordermay
incorrectlyfilled.The
appropriateamountorwrong
medmaybeplacedinbag.

Theordermaynotbeclear
aswrittenorunclearly
writtenduetodifficultyin
readinghandwritting.

Inappropriatedrugwillbe
placedinbagor
inappropriatedosewillbe
placedinbag.

Step

Description

12

Sealedbag&copyofordersenttoDepartment

FailureMode

Causes

Effects

Theordermaynotbeplaced
inthebagandthereforemay
notbetheappropriate
patient'sorderwhenthebag
issealed.

Theroutineisnotfollowed
whennewpersonisfilling
preoporderforthat
department.

IncorrectHRMmaygoto
incorrectpatientdepartment
orbag.

Step

Description

13

PriortoadministrationofHRMdoublecheck5Rs&expiration

FailureMode

Causes

Effects

Priortoadministrationof
HRM'sthenursemayforget
thedoublecheckand5Rs&
ckg.expirationdatescreating
mederror.

Shortstaffing,rushingand
nottakingthepropersteps
asselfcheck&the5R'sand
doublecheckmethods,which
shouldbereveiwedin
orientation.

Thenegatingofroutinesteps
whichareplacedtodeter
mederrorsofHRM'sarethe
reasonstheymayoccur.

Step

Description

14

UnusedHRMarerebaggedwithordertonextdepartment

FailureMode

Causes

HRMdoesnotgetreturnedto Staffisrushed,notpaying
bagandplacedinadvertently attentionorinterruptedand
indepartmentandmaybe
humanerrorresults.
usedasanotherdrug.

Effects
HRMisnowplacedwith
regulardepartmentaldrugs
andmaybeusedasalook
alikedrugbymistake.

Step

Description

15

AllhighdoseHeparinneedstobereturnedtoPharmacyviabag
containingorder

FailureMode

Causes

HRHeparinmaybeleftin
Staffrushing,interruptions
departmentandinadvertently andnotpayingattention
placedwithregulardrugs.
whileusingHRM

Effects
HRMwillbeleftin
departmentandplacedwith
regularmedsand
inadvertentlybeusedasa
lookalikedrugandbeused
inerror.

ofmederror.

Occ Det Sev RPN Actions

5

10

250 NeverAdministerHRM
withoutDoublechecksystem
takingplacewithatleastone
otherappropriateindividual.

Occ Det Sev RPN Actions

2

10

160 Heparininhighdoseformof
greaterthan100unitsper
ml.mustberecognizedas
HRMandappropriately
baggedandlabeledwith
"highalertdoublecheck"
sticker.

Occ Det Sev RPN Actions

3

10

270 Preopordersforspecific
HRM'sshouldbecopiedand
senttobothpreopand
pharmacyinatimely
mannerforproperfillingand
labelingperpatient/doctor
order.

Occ Det Sev RPN Actions

2

10

180 Theunderstandingandread
abilityoftheorderiscritical
tofullfillingtheorderfor
preparationinthebagand
labelingitasHRM.Any
questionsshouldinitiatecall
tophysicianforclarification.

Occ Det Sev RPN Actions

1

10

90 Thefollowingofroutine
stepswhendealingwith
HRM'sisputinplaceto
assistinpreventionof
anticipatederrorsoccurring
andshouldbefollowed.

Occ Det Sev RPN Actions

2

10

140 ImperativetoReviewwith
newnursesonstafftheHRM
Policyandourtreatmentof
routinestepsindealingwith
HRMstopreventerrors.

Occ Det Sev RPN Actions

4

10

320 Payingfullattentionwhen
workingwithHRMuseofthe
doublechecksystemwith
anotherpersonshould
preventoccurrence.

Occ Det Sev RPN Actions

4

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9683&ScenarioId=11215&Type=1

10

320 Alwaysbeattentivewhen
usingHRMandfollowdouble
checkprocedure.

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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

Step

Description

16

RestockHRMandshredpatientorder

FailureMode

Causes

Pharmacynursefailsto
segregatedrugasHRMandit
isplacedwithregular
pharmaceuticals.

Staffmemberreturningdrug HRMmaybeconsidereda
mayleaveitorpharmacy
lookalikedrugandusedas
nursemayberushedand
anotherdrug.
inadvertentlyplaceitwith
regularmeds.

Effects

Occ Det Sev RPN Actions

4

10

320 StayingfocusedonHRMand
notallowinginteruptionsor
toberushedsodrugcanbe
properlystored.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

3754

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=9683&ScenarioId=11215&Type=1

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