Nursing rca scenario
Failure Modes and Effects Analysis (FMEA) Failure Modes and Effects Analysis (FMEA) is a tool for conducting a systematic, proactive analysis of a process in which harm may occur. In an FMEA, a team representing all areas of the process under review convenes to predict and record where, how, and to what extent the system might fail. Then, team members with appropriate expertise work together to devise improvements to prevent those failures — especially failures that are likely to occur or would cause severe harm to patients or staff. The FMEA tool prompts teams to review, evaluate, and record the following: • Steps in the process • Failure modes (What could go wrong?) • Failure causes (Why would the failure happen?) • Failure effects (What would be the consequences of each failure?) Teams use FMEA to evaluate processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. This emphasis on prevention may reduce risk of harm to both patients and staff. FMEA is particularly useful in evaluating a new process prior to implementation and in assessing the impact of a proposed change to an existing process. Copyright © 2017 Institute for Healthcare Improvement. All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement. IHI’s QI Essentials Toolkit includes the tools and templates you need to launch and manage a successful improvement project. Each of the nine tools in the toolkit includes a short description, instructions, an example, and a blank template. NOTE: Before filling out the template, first save the file on your computer. Then open and use that version of the tool. Otherwise, your changes will not be saved. • Cause and Effect Diagram • Driver Diagram • Failure Modes and Effects Analysis (FMEA) • Flowchart • Histogram • Pareto Chart • PDSA Worksheet • Project Planning Form • Run Chart & Control Chart • Scatter Diagram
QI ESSENTIALS TOOLKIT: Failure Modes and Effects Analysis (FMEA) Institute for Healthcare Improvement ? ihi.org Instructions 1) Select a process to evaluate with FMEA. Evaluation using FMEA works best on processes that do not have too many sub-processes. If you’re hoping to evaluate a large and complex process, such as medication management in a hospital, divide it up. For example, do separate FMEAs on medication ordering, dispensing, and administration processes. 2) Recruit a multidisciplinary team. Be sure to include everyone who is involved at any point in the process. Some people may not need to be part of the team throughout the entire analysis, but they should certainly be included in discussions of those steps in the process in which they are involved. For example, a hospital may utilize couriers to transport medications from the pharmacy to nursing units. It would be important to include the couriers in the FMEA of the steps that occur during the transport itself, which may not be known to personnel in the pharmacy or on the nursing unit.
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