June 18th 2018 1

FMEA Template

This template can be used to document the completed FMEA including follow-up
actions and measures. Revise this template as necessary to meet your needs. Review
the Guidance for Failure Mode and Effects before using this template.

Process analyzed: To understand how the hardware on a clinician’s workstation may

fail during project implementation
Team leader: Dr. Waverly

Team members:

Name Position Name Position

Dr. Jones Physician Lead Ms. Smith Team Member

Mrs. Jones Super User Ms. Felps Team Member
Mrs. Wright Team Member
Mr. Lawrence Team Member

Describe your process steps (flowchart): As per the suggested guidance, you might
use sticky notes on separate papers.

Turn on Turn on Turn on Log into

Router Printer Workstation Workstation

Identify what could go wrong during each step of the process. You might use
sticky-notes indicating what could go wrong for each step. Line these up beneath each
process step.

Process What could go wrong

Turn on - Router does not turn on

Router - Router does not connect to the internet
- Router not configured correctly

University of San Diego © 2016. All Rights Reserved.

June 18th 2018 1

Turn on - Printer does not turn on

Printer - Printer does not connect to network
- Printer is broken

Turn on - Workstation does not turn on

Workstation - Workstation does not connect to the network

Log into - End User failure

Workstation - Slow connectivity

For each item identified that could go wrong, rate each for the seriousness of this
outcome (severity) and how often the mistake is likely to occur (probability)

Category Outcome Rating (Severity)

Rating Outcome Category Description

5 Catastrophic Power Outage

4 Major Unable to access cloud-based

EHR at all
3 Moderate Intermittent access to cloud-
based EHR
2 Minor One workstation not operational
1 Near Miss Workstation not plugged into
power outlet
Failure Probability rating scale (Probability)

Rating Outcome Category Definition

5 Very High probability: 1 failure in 1 attempt
failure is most inevitable

4 High: repeated failures 1 failure in 5 attempts

3 Moderate: occasional 1 failure in 10 attempts
failures
2 Low: relatively few 1 failure in 50 attempts
failures
1 Remote: failure is < 1 failure in 100 attempts
unlikely

University of San Diego © 2016. All Rights Reserved.

June 18th 2018 1

Review your ratings and decide on your process failures identified as high priority for
corrective actions. List the process failures you will focus on in the table below.

Process What could go wrong Severity Rating Probability

Rating

- Router does not turn - 5 - 1

on - -
Turn
on - Router does not - 4 - 2
Router connect to the internet - -
- Router not configured - 3 - 2
correctly
- Printer does not turn - 5 - 1
on - -
Turn on
Printer - Printer does not - 3 - 2
connect to network - -
- Printer is broken - 3 - 2

- Workstation does not - 5 - 1

Turn on turn on - -
Workst - Workstation does not - 4 - 2
ation connect to the network

- End User failure - 2 - 2

Log - Slow connectivity - 3 - 2
into
Workst
ation

Describe your corrective actions for process failures identified as high priority:
Before determining your corrective actions for process failures, consider whether you
should conduct a systematic analysis to determine the root cause of each failure chosen
for action. If necessary, use techniques such as the five whys, flowcharting, or the
fishbone diagram to assist in identifying the root causes. Additional tools are available
that guide the use of each of these techniques. It is helpful to keep any of these
analyses with your PIP documentation for future reference. In the table below, describe
University of San Diego © 2016. All Rights Reserved.
June 18th 2018 1

each root cause for each process failure, and then enter your specific actions to reduce
or eliminate the failure, your completion timeframe, and the responsible individual or
group.

Root Cause of Specific Actions to Completion

Process Responsible
Process Reduce or Eliminate
Failure Individual/Group
Failure the Failure Time Frame

Router Place all connections

7 days IT installation group
unplugged securely out of site
All hardware should be
Router burned
plugged into surge 7 days IT installation group
out
protectors
Turn on Router does
No internet provider,
Router not connect to 1 day IT installation group
contact provider
internet
Router not
Configure router to
configured
EHR system 7 days IT installation group
correctly
specifications
Printer Place all connections
7 days IT installation group
unplugged securely out of sight
Printer does Hard wire printer Wi-Fi
Turn on not connect to access instead of 7 days IT installation group
Printer network wireless
Devise practice protocol
Printer is
for repair and 7 days Key Stakeholders
broken
replacement
Workstation Place all connections
7 days IT installation group
unplugged securely out of sight
Workstation
does not meet Upgrade workstation to
Turn on cloud EHR meet cloud EHR 7 days IT installation group
Workstat minimum minimum specifications
ion requirements
Devise practice offline
Power outage 7 days Key Stakeholders
protocols
Natural Devise natural disaster Key Stakeholders, IT
14 days
Disaster offline protocols installation group

University of San Diego © 2016. All Rights Reserved.

June 18th 2018 1

Measures of Success

Measure(s) of Success
(How we
will know if this action is
successful)
(Consider measures
Corrective Reporting Schedule and Individual or
of how often the failure is still
Action
occurring after process changes Group Responsible for Reviewing Results
and the incidence of adverse
events related to the failure)

Place all
Count the number of accidental
connections
equipment unplugging events per Dr. Waverly, Dr. Jones, Mrs. Jones
securely out
week
of sight
Devise
practice Have training module that all staff
protocol for need to complete on a yearly basis Mrs. Jones
repair and – measure completion rate
replacement
Devise
Have training module that all staff
practice
need to complete on a yearly basis Mrs. Jones
offline
– measure completion rate
protocols
Devise
natural Have training module that all staff
disaster need to complete on a yearly basis Mrs. Jones
offline – measure completion rate
protocols

Signature of FMEA leader/facilitator__________________________ Date __________

University of San Diego © 2016. All Rights Reserved.