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Prior to conducting the actual hazard analysis, there are steps to be taken in preparing for the FMEA. First, you must select the process to be examined. In this scenario, it will be the administration of conscious sedation. Secondly, you want to assemble your team of interdisciplinary professionals. As mentioned above, in this scenario, I would assemble a team inclusive of RN’s who are trained in the current process, a physician, a pharmacy representative, a member of risk management and a unit manager. Thirdly, you want to make a graphic representation of the current process and this is where you will derive the possible failure modes. (Cronrath et al., n.d.). By making a graphic representation of the steps in the current process, step by step, you can then branch off of each step and identify where potential failures could occur. In the scenario presented, there where opportunities for errors all along the way from the initial verbal order, to no verification of medication names or doses and down to the patient not being continuously monitored throughout the process and
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Three Steps
Now that the interdisciplinary team has identified the failure modes, they are now look at likelihood of occurrence, the likelihood of detection and the severity of occurrence if the process fails. Each of these categories is given a score between 1 and 10. For example, when considering occurrence, a score of 1 would mean it is highly unlikely that an event will occur and 10 would mean that it is very likely to occur. A score of 1 for detection, means it is likely to be detected and 10 means it will not be detected and for severity 1 would be less severe and a score of 10
would mean a catastrophic outcome, such as the patient’s death in this scenario. These scores are then multiplied L x D x S to come up with a RPN, or Risk Priority …show more content…
This new process would be rolled out on a test unit, in this case the ER, since that is where the adverse event occurred in this scenario. Staff on this unit will all be trained in and implement the new process. Measurement is a critical part of the improvement process. It is important to know if the changes that were made to the process were effective in improving care in similar situations. First you must start by having a measurable goal. In this case, the goal would be to reduce the number of patient deaths due to over sedation by 90 percent in the test period of 3 months. The IHI website offers an interactive FMEA tool that allows you to create a FMEA based on the original process and a FMEA based on the new process and you can track your plan over time to see if the changes made are leading to improvement. Selected members of the project team, would be assigned specific roles in the tracking process. For example you would need a clinical leader, who is someone that has enough authority in the organization to test and implement the change, a technical expert who knows the subject and understands the process thoroughly, and a day to day leader, who is the driver of the project, overseeing data collection and assuring that tests are being implemented. ("Science of Improvement: Forming the Team," 2016). This team will use the current data and the data collected and utilize the FMEA Tool Report to see if the changes
Three Steps
Now that the interdisciplinary team has identified the failure modes, they are now look at likelihood of occurrence, the likelihood of detection and the severity of occurrence if the process fails. Each of these categories is given a score between 1 and 10. For example, when considering occurrence, a score of 1 would mean it is highly unlikely that an event will occur and 10 would mean that it is very likely to occur. A score of 1 for detection, means it is likely to be detected and 10 means it will not be detected and for severity 1 would be less severe and a score of 10
would mean a catastrophic outcome, such as the patient’s death in this scenario. These scores are then multiplied L x D x S to come up with a RPN, or Risk Priority …show more content…
This new process would be rolled out on a test unit, in this case the ER, since that is where the adverse event occurred in this scenario. Staff on this unit will all be trained in and implement the new process. Measurement is a critical part of the improvement process. It is important to know if the changes that were made to the process were effective in improving care in similar situations. First you must start by having a measurable goal. In this case, the goal would be to reduce the number of patient deaths due to over sedation by 90 percent in the test period of 3 months. The IHI website offers an interactive FMEA tool that allows you to create a FMEA based on the original process and a FMEA based on the new process and you can track your plan over time to see if the changes made are leading to improvement. Selected members of the project team, would be assigned specific roles in the tracking process. For example you would need a clinical leader, who is someone that has enough authority in the organization to test and implement the change, a technical expert who knows the subject and understands the process thoroughly, and a day to day leader, who is the driver of the project, overseeing data collection and assuring that tests are being implemented. ("Science of Improvement: Forming the Team," 2016). This team will use the current data and the data collected and utilize the FMEA Tool Report to see if the changes