9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

FoodandNutrition:ExpiredProduct
AdvocateTrinityHospital
Chicago,Illinois,UnitedStates
HospitalCommunity

Aim:ReducetheRiskPriorityNumber(RPN)foroutdatedfoodandnutritiondeliveryprocessby50%by6/1/2010.
ProcessData
Date:04/05/2010
Step

Description

Productdelivered(Tue&Fri)

FailureMode

Causes

Effects

Outdatedproductdelivered

Doublecheckingdidnot
occur

Outdatedproductstockedon
shelves

FailureMode

Causes

Effects

Expiredstocknotremoved
fromshelvingincooler

Timepressure
Visionimpairment
Expirationdatestamp
defective

Expiredproductreaches
patient

Step

Description

Stockrotatedincooler

Step

Description

Outdatedstockremovedfromshelves

FailureMode

Causes

Effects

Outdatedstockplacedon
floorinfrontofshelving
Staffplaceproductbackon
shelving

Stafftryingtokeepproduct
offoffloors

Outdatedproductmixedwith
newproduct

Step

Description

Newproductplacedonshelves

FailureMode

Causes

Effects

Oldproductpushedtoback
ofshelving

Timepressure
Assumesomeoneelse
checkedtheexpdate
Expdatescratched
(defective)

Oldproductnotusedbefore
expirationdate

Step

Description

Placeexpiredproductoncart

FailureMode

Causes

Outdatedproductnotplaced
oncart

Don'tcare
Outdatedproductremainson
Distracted
shelvingmixedwithnew
Multitasking
product
TimePressure
Thoughtthedateseenwas
OK
Visionimpairementofperson
Environmentallightingpoor

Step

Description

Productremovedtocompletefoodline

Effects

FailureMode

Causes

Expirationdatenotchecked
priortoremovingproduct
fromcontainer.

TimePressure
Outdatedfoodreaches
Assumesomeoneelse
patient
previouslycheckedthe
expirationdate.
Visionimpairmentofperson
Environmentallightingpoor
inrefrigerator
Don'tcare
Distracted(talking,music,
mindelsewhere)
Multitasking

Step

Description

Productbroughttofoodpreparationstation

Effects

FailureMode

Causes

Effects

Expirationdatenotchecked

Timepressure

Outdatedfoodreaching

Occ Det Sev RPN Actions

3

192 Doublecheckwithvendor
whenfooddeliveredand
stockedonshelvesincooler.

Occ Det Sev RPN Actions

8

320 Doublecheckwhenfood
delivered

Occ Det Sev RPN Actions

8

320 Placeredstickeronoutdated
openproduct
Placeunopenedoutdated
productincagelocatedin
meatcooler

Occ Det Sev RPN Actions

8

10

400 Doublecheckexpiration
dateswhenproduct
deliveredandplacedon
shelving.

Occ Det Sev RPN Actions

8

320 Ifoutdatedproductcontainer
opened,thenthrowaway
container.
Ifoutdatedproductcontainer
unopened,thenplacein
cagelocatedinmeatlocker
forcreditwithvendor.

Occ Det Sev RPN Actions

8

10

400 Doublecheckproduct
containerforexpirationdate.
AttentiontoDetail

Occ Det Sev RPN Actions

8

10

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=10552&ScenarioId=12182&Type=1

400 Doublecheckexpirationdate

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9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
Assumedsomeoneelse
patient
previouslychecked
expirationdate
Visionimpairmentofperson
Environmentallightingpoor
Expirationdatestamp
scratched(defective)
Don'tcare
Distracted
Multitasking

whenproductcontainer
openedatfoodpreparation
station.

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

2352

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

10=VerylikelyitWILLNOTbedetected

Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)

Annotation
Event:OutdatedFoodProduct

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=10552&ScenarioId=12182&Type=1

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