9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

PatientIdentification&BloodBands
OurLadyofLourdesRMC
Lafayette,Louisiana,UnitedStates
HospitalCommunity

Aim:ReducetheRPNforpatientidentificationandtheadministrationofbloodproducts.
ProcessData
Date:05/24/2004
Step

Description

Registrar/nurseplacesCLEARIDbandsonOP,EDpatientsnot
admitted&SNFptforOPprocedures.

FailureMode

Causes

Effects

Occ Det Sev RPN Actions

OPdoesnotreceiveclearID OPPtbypassedadmitting
band.
andwentstraightottheOP
department.

CareisprovidedtoOPpt
withoutIDband.

10

280

EDpatientdoesnotreceive
clearIDband.

Ptgoesdirectlytoback
withoutIDfromtriageor
fromAcadian

EDpatientcaredforwithout
ID.

10

490

SNFpatientdoesnotreceive
cleararmbandpriortoOP
procedure.

AdmitdoesnotgetOPID
bandtoSNFpriortopt
leavingfloor.
PreAdmitpaperwork&ID
banddeliveredtoSNFthe
daybefore,butSNFfailsto
placeIDbandonptpriorto
OPprocedure.

CahrgeforOPprocedurego
towrongaccount.

28

Step

Description

RegistrarplacesWHITEIDbandforIPadmits.

FailureMode

Causes

IPdoesnotreceivewhiteID
bandattimeofadmit.

Acadiangoestofloorwithpt PtarrivesonunitwithoutID
&doesnotstopinadmit.
band.
Ifptisnotpreadmitted
whiteIDisnotreadywhenpt
arrives.

Effects

10

10

PatienthastwoWHITEID
bands.

AwhiteIDbandisplacedon
EDptuponadmitbecause
registrarthinkstheywill
probablybeadmittedand
whentheyenduponfloora
differentregistrarpreparesa
newIDandsendsittothe
floor.
EDdoesnotletRegistrars
knowwhenptleavesforfloo

196

Ptarrivesonfloorwithtwo
IDbandsoranIDbandwith
aEDlabel.Thenurseonthe
floorcouldaddthesecondID
bandwithoutknowingtotake
thefirstoneoff.Laterthe
lab,etcdoesnotknowwhich
bluetagisvalidandpatient
wouldneedtoberedra

Step

Description

RegistrarplacesYELLOWIDbandforptsbeingadmittedto
SNF/Rehab.

FailureMode

Causes

PatientisadmittedtoSNF
withoutyellowIDband.

RegistrarfailstoprepareSNF PatientadmittedtoSNF
paperworkpriortopt
withoutyellowIDbandand
transferordoesnotreceive SNFaccount#.
amessagestatingpthasa
SNFtransfer.

Effects

Step

Description

RegistrarremovesWHITEID/bluetag&putssamebluetagin
YELLOWIDband&placesonSNF/RHBpt.

FailureMode

Causes

YellowIDbandisapplied
withoutthesamebluetag.

PatientdoesnothaveWHITE SNF/RHB&Hospiceptshave
IDatall.
IDbandwithadifferentblue
RegistrarappliesYELLOWID tag.
withoutremovingWHITEID.
RegistrarappliesYELLOWID
andforgetstoswitchoutblue
tag.

Effects

Step

Description

StaffreplaceWhite/YelIDband/bluetagandnotifiesnursetocallBB
&exceptionreportcompleted.

FailureMode

Causes

White/YellowIDbandis
replacedandBBisnot

StaffapplyingnewIDwillnot Pttorecievebloodproducts
notifynurse.
andrealizethebluetagis

Effects

Occ Det Sev RPN Actions

Occ Det Sev RPN Actions

1

1 Designatedadmitstaffto
preadmitptspriorto
transferringtoSNF.

Occ Det Sev RPN Actions

7

10

10

700

Occ Det Sev RPN Actions

4

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=414&ScenarioId=431&Type=1

10

280

1/3

9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

notified,andanexception
reportisnotcompleted.

NursewillnotcheckwithBB
orcompleteandexception
report.

incorrectandthepthastobe
redrawn.

Step

Description

RegistrarpreadmitsptandplacesIDbandinchartforrecievingdept.

FailureMode

Causes

Effects

Preadmittedpatientsdonot IDgetsmisplacedfromAdmit PatienthastowaitwhileID

haveIDbandwiththeirpre orDTS(orotherdepts)
bandpreparedbyadmitstaff
admitchart.
WrongptIDplacedinchart. anddeliveredtodept.
WrongIDareidentified
immediatelybystaffapplying
IDbnad.
Step

Description

DTSorRecievingdeptplacesIDbandonpreadmittedpatientatthe
timeofAdmit.

FailureMode

Causes

IDbandisnotplacedonptat Staffmayhavefailedto
timeofadmittodept.
followP&P.

Effects
Patienthasprocedurewithout
IDband.

Step

Description

PreAdmittedptsreturningforaT&M,thechartisretrievedfromDTS
&theIDbandisaplied.

FailureMode

Causes

Effects

TheIDbandisnotinthe
chartfromDTSanda
differentIDispreparedand
placedonthept.

DTStakestheIDbandsout
ofthecharttopreparefor
thenextday.

PtshowsupinDTSthenext
daywithanIDinplaceand
DTShasanotherIDforthe
samept.

Step

Description

PreAdmit<72hrs,drawT&M&placeIDbandonpt,ptinstructedto
notremoveIDband.

FailureMode

Causes

IDbandisnotonpt.attime
ofadmit.

StaffforgottoputIDbandon PtmusthaveT&Mredrawn
pt.
PatientremoveIDband.

Effects

Step

Description

10

PreAdmits>72hrs,obtainorderforT&SandT&Mdayofprocedure,
&chartforDTStodoT&Matadmit

FailureMode

Causes

Effects

Occ Det Sev RPN Actions

1

Occ Det Sev RPN Actions

1

10

10

Occ Det Sev RPN Actions

4

Occ Det Sev RPN Actions

4

10

280

Occ Det Sev RPN Actions

Order&T&Sarenot
Afterhours&noonFirday
PatienthasT&Mdonetheday
obtained,patientdoesnot
difficulttoobtainorder.OKto oftheadmit.
returnpriortoadmitforT&M. writeorderforDr.Schutte
pts,butdonothavethisis
writing.
Sometimesptdoesnotor
cannotreturn.

10

40

T&SandtheT&Maredoneas Thelab,BBortheBOdonot DoublebillingFraudissue.

ordered,buttheptis
knowtoremovetheT&S
chargedforbothtest.
fromthebill.

10

10

400

Step

Description

11

DTSidentifiesthatpthadT&S,ordersT&M,callslabtoredrawpt.

FailureMode

Causes

Effects

DTSdoesnotrealizethatpt
hadT&SandneedsaT&M
anddoesnotordertheT&M.

DTSassumesthattheT&M
wasdonebecausethereisa
yellowlabelontheorderand
theptpreadmitted.
P&Pdoesnotstatethat
yellowlabelsorIDbandsare
appliedforT&S(itdoesnot
mentionT&Satall).
P&Pdoesnotstatethatthe
admitting,floor,

Ptdoesnothaveblood
productsreadyintimefor
procedure.
Procedurecouldbe
cancelled.
Greatpotentialformany
unsatisfiedcustomers!!!!

Step

Description

12

LabdrawsT&Mandmarksspecimenwithbluetagnumber&marks
IDband&orderswithyellowlabel.

FailureMode

Causes

Effects

Labdoesnotredrawpt.

T&Mnotorderedbystaff.
Usedtohavesbombsbut
thisissuehasbeen
addressedwithnewlab
software.

Ptdoesnothaveblood
ready.

Step

Description

13

IfabluebloodIDtagisnotonthepttheptwillberedrawnpriorto
administeringbloodproducts

FailureMode

Causes

Thepatientdoesnothavean CUTOFF!
IDwithabluebloodtag.
SOILED!
Ptremoves.

Effects
Pthastoberedrawn,could
causedelayinprocedure,
etc.

Occ Det Sev RPN Actions

7

10

490

Occ Det Sev RPN Actions

1

10

10

Occ Det Sev RPN Actions

4

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=414&ScenarioId=431&Type=1

10

40

2/3

9/15/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

Step

Description

14

StaffremovingtheIDbandareresponsibleforreplacingtheID,
usingtheoriginalbluetag

FailureMode

Causes

Effects

StaffremoveIDbandsand
donotreplacethem.

IDneedstoberemoveddue
toprocedure,becomes
soiled,etc.

Pthastoberedrawnbecause
newIDbnadhastobe
reapplied.

Step

Description

15

RegistrarswillplaceadmitlabelonGREENIDbandforptscoming
fromMDofficesfortransfusions.

FailureMode

Causes

LabelisnotplacedonGREEN Ptmaybypassadmit&ED
IDband.
admitafterhours.

Effects
Ptissenttoadmittoobtain
labelorstaffcalladmitto
obtainlabelforpt.

Occ Det Sev RPN Actions

4

10

160

Occ Det Sev RPN Actions

1

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

3421

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=414&ScenarioId=431&Type=1

3/3