3/18/2020 Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report

Failure Modes and Effects Analysis (FMEA) Tool

Identifying Infection Control

Southlake Regional Health Centre

Aim: To reduce the risk priority number for infection control process

Process Data

Date: 02/20/2006

Step Description
1 Infection control questions asked through glass partition.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Step missed questions not Language barrier, staff talking Potential infection missed and 4 5 1 20 Signage to alert patient to
understood by patient. quickly, patient embarassed, others put at risk screening process and why
Patients don't tell truth. hoping for faster service. necessary.

Step Description
2 Infection control sheet filled out.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Unnecessary precaution, Inadequate assessment info Risk spread of infection in the 8 8 2 128 Ask questions in step 1 to
inappropriate precaution. and time to decide. department. Becomes protect Triage nurse but
overwhelmed with complete infection control
unnecessary precautions, tend form in step 4.
to be ignored, necessary ones
too.

Step Description
3 Patient asked to carry out infection control precautions, apply mask or
hand wash.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Patient refuses to comply, Children, cognitive Risk of spread of infection. 3 1 2 6 Staff to wear appropriate
patient unable to comply. impairment, too sick to wear PPE. Staff to be clear with
mask, isolation unavailable. instructions and reinforce
behavior.

Step Description
4 Patient brought to Triage area for assessment.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Staff not wearing PPE. In Yes Interpretation of directions on Temperatures not recorded, 5 1 1 5 Change form, example
section A temperature not form. all should be. provided. Staff ED.
recorded in section B on
screening tool.

Step Description
5 Infection control precautions entered in computer.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Incorrect precaution entered. Not understanding catagories. Risk of infection transmission. 8 7 5 280 Change drop chart on
Computer entry errors. computer add BSP for nil
most used order by staff ED

Step Description
6 Patient sent to waiting area.
Failure Mode Causes Effects Occ Det Sev RPN Actions
No isolation available, patient Lack of space in department Risk of spread of infection. 8 8 8 512 Redesign waiting room and
noncompliant with infection and waiting room. Risk to immuno compromised Triage area.
control precaution. patients.

Step Description
7 Patient brought to room in Emerg.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Precautions not passed on to Infection control not on chart Infection risk to staff and 8 8 8 512 Revise screening tool to
ER staff. face. Many people taking other patients. include infection control field.
patients to department. Signs Add infection control status
to desks monitor board. Add

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3/18/2020 Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
not put on rooms. Infection infection control status to
control not on desk monitor. chart face (precaution sheets
will do? for now.)

Step Description
8 RN enters room for initial assessment.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Staff enter room unprotected Sign not on door. Staff not Risk of spread of infection to 8 5 2 80 Add infection control to desk
for initial assessment. checking Tracking Board. staff. monitor. Triage to put signs
up consistently. Staff
education.

Step Description
9 Health professionals and other services enter room.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Other department staff enters Signage not coordinated. Risk of spread of infection. 8 5 2 80 Staff compliance with
room unprotected or Triage info incorrect. Signs coordinating door signs and
inappropriate use of PPE. not visable from all angles in Tracking Board. Removing if
the acute room. Not enough precaution lifted. Buy more
isolation carts. carts.

Step Description
10 Patient and family informed of required infection control precautions
and risks.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Family not using PPE and Family not informed of Risk of spread of infection to 8 3 2 48 More family teaching,
other infection control infection control measures to family and community. possible restriction of
measures. take. Family noncompliant. visitation.

Step Description
11 Patient transported for test outside of department.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Patient not wearing necessary No infection control signage Risk of spread of infection to 9 8 5 360 Infection control signage on
PPE. staff in other on chart. Receiving other staff and other areas of chart. Porters informed and
departments unaware of department not notified i.e. the hospital. protected if reading Tracking
infection control precautions. by phone. Board/door signs. Incoming
Porters not wearing PPE. department aware in
advance of patient arrival.
Increase use of portable
testing i.e. ultrasounds.

Step Description
12 Patient admitted to Hospital.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Inappropriate bed Bed Allocation Department a) Patient waiting in Emerg 6 3 6 108 Put in patient infection
assignment. unaware of correct infection for isolation bed control status on chart face
control status. unnecessarily. when decision to admit
b) Patient on infection control made.
being sent to floor to
inappropriate bed and
infection risk.

Step Description
13 Patient transferred to in-patient unit with report.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Patient sent to floor with RN either not aware of correct Risk of infection to porters, 4 1 6 24 Patients infection control
infection control status status or failed to report same floor, staff and patients. status put on chart face
unreported. to receiving RN. when decision to admit
made. ER RN must document
infection control status on
chart and verbal report to
receiving unit.

Calculated Totals

Total Risk Priority Number for the process 2163

Occ: Likelihood of Occurrence (1-10)

Annotation
None

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