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InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
FailureModesandEffectsAnalysis(FMEA)Tool
UpgradedCathLab
StringfellowMemorialHospital
Anniston,Alabama,UnitedStates
HospitalCommunity
Aim:OpenupgradedCathLab
ProcessData
Date:01/22/2015
Step
Description
SupplyStoragereducedspace
FailureMode
Causes
Unabletofindcriticalsupplies ReducedSpace
duringprocedure
Effects
DelayedProcedure
Step
Description
PowerSourceMaynotbeabletouseplugsforallequipment
FailureMode
Causes
Maynotbeabletouseplugs
forallequipment
Notenough'red'plugs.
Delayinprocedure
Wouldoverloadcertainplugs.
Step
Description
MedicalAirSupplyBoxLocationisunsafe
Effects
FailureMode
Causes
Effects
Triphazard.
Boxnotmovedwith
renovation.
Interruptionofoxygen&
suction.
Step
Description
Newdocumentationsystem
FailureMode
Causes
Effects
Staffunabletousenew
systemorslow.Unableto
accessinfofromprevious
system.
Unfamiliarwithsystem.
Inaccuratedocumentation.
Physiciansupsetwithdelay.
FailureMode
Causes
Effects
EquipmentFailure
NewanduntestedStaff
unfamiliarwithequipment
Unabletocomplete
procedure
FailureMode
Causes
Effects
NewequipmentforCathLab
staffnotfamiliarandmay
notuseitproperly.Itisa
regulatoryrequirement.May
needspecialequipmentor
codesonotmayavailable.
Newequipment.
Equipmentnotused.
Step
Description
EquipmentFailure
Step
Description
Capnography
Nasalcannulaisdifferent
thanwhatiscurrentlyused.
Unabletousecapnograpy.
Step
Description
Temperature&Humidity
FailureMode
Causes
Effects
Equipmentincreasestemp.
Increasedhumidity.
Equipment
Equipmentmightoverheat
couldshutdownCathLab.
Humiditymightincreaserisk
ofinfection.
10
100 Lookforstoragespacein
otherareas.PerKen
storageareasmustbe
monitoredfortempand
humidity.Knowwhich
suppliesdon'tneedtohave
temp/humcontrol.
280 Testpriortoopening.
10
800 DiscusswithPlantOpsto
haveitrelocated.Or
redesignbox.PerKenwant
togetthetableinfirstand
thenseeiflocation/design
needstobechanged.
10
200 Keepa'host'computerwill
ptinformationfromprevious
system.Inaccurate
documentationcanbe
amended.
10
50 Testequipmentbefore
procedures.StaffEducation
abouthowtotroubleshoot
theequipment.
10
200 Mgrtoreviewrequirements.
Stafftrainingbeforemoveto
renovatedCathLab.
10
250 Wehave10instock.
Carefusionrepshouldsupply
moreasneeded.
10
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19031&ScenarioId=21045&Type=1
800 DiscusswithPlantOps
Directortoseeifdesignhas
beenchanged.PerKen,
MechanicalRoomsize
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9/14/2015
InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
increasedandcantakean
higherheatload.Willneed
tobetestedandadjusted
aftercompletionof
renovation.
Step
Description
ScrubSink
FailureMode
Causes
Effects
Limitedspacemakesproper
scrubbingdifficult.
Designspaceissue.
Improperscrubbing
increasedinfectionrisk.
Physiciandissatisfaction.
Watertempnothotenough
Design.
Physiciandissatisfaction.
Increasedriskofinfection.
FailureMode
Causes
Effects
Notenoughpressure
Design
Increasedinfectionrisk
Step
Description
PositiveAirPressure
Step
Description
10
Lengthoftimeittakestomove
FailureMode
Causes
Effects
Needtohaveatleast12
hourswithnoprocedures.
Emergencyatotherfacility.
Needtodoallcathshere.
FailureMode
Causes
Effects
Sizeofworkspaceslightly
decrease
Designofroom
Step
Description
11
WorkSpace
Description
12
Installationofunneededequipment
Step
Description
13
Dooronright(goingin)warpedtoomuchspaceatbottom
FailureMode
Causes
Effects
Toomuchspaceatbottom
Doorwarped
Affectpositivepressure
environment
FailureMode
Causes
Effects
Equipmentnotavailable
Wirescutduringconstruction Unabletoperformultrasound
ofcoronaryarteries.
Description
14
IVUSnotoperable
10
350 Redesign.NewSink.Per
Ken,sinkwillbeinsame
locationbutwillbelarger.
10
10
500 DiscusswithPlantOps.
Redesign.PerKennewhot
watertankbeinginstalled.
10
250 TalkwithPlantOps
10
210 First,moveenoughsupplies
foranemergencycath.Plan
tohavenoactivityforat
least12hoursnotifyER
andcardiologists.
Step
Step
10
500 Organizationadded
cabinets.Movesome
equipmenti.e.balloon
pump.
70 Repairorreplacedoor
10
250 TrytohaveIVUSrepaired
beforemove.Ifthatisn't
possibleinformcardiologists
thatitisn'tavailable.
CalculatedTotals
TotalRiskPriorityNumberfortheprocess
4810
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=19031&ScenarioId=21045&Type=1
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