Oncology Chemotherapy
Content
Failure Modes and Effects Analysis (FMEA) Tool
Copy of Oncology/Chemotherapy
The Richland Hospital, Inc.
Richland Center, Wisconsin, United States
HospitalCommunity
Aim: Reduce the RPN for the Oncology Referral/Chemotherapy process in 6 months
Process Data
Date: 03/15/2004
Step
Description
1
Patient referred for Oncology Consult
Failure Mode
Causes
Effects
Patient workup incomplete
for the type of cancer being
seen for
Lack of knowledge of
referring physician.
Patient doesn't get good
information on the first visit.
Needs to scheduled an extra
visit.
Delays patient treatment
Oncologist schedule changes
Walkins
Gets additional patients
scheduled
MD on call in Madison and
needs to leave early
Patient inconvenience
Time is required to change
the schedule staff resources
Step
Description
2
Charts pulled and prepped
Occ Det Sev RPN Actions
10
5
7
2
4
5
350 Arrange a Grand Rounds
Program
Develop referral templates
40
Failure Mode
Causes
Effects
All charts not available for
Oncology clinic
Schedule not complete
Walkins
Referrals day before clinic
Patient information not
available for physician to use
8
7
10
560 Work with Medical Records
to educate staff
Compare charts with
schedule day before
Compare charts with new
schedule day of
All required patient
Referring physician didn't
information not in chart when dictate note yet.
patient seen by Oncologist
Referring physician didn't
write an order for referral.
Medical Records didn't locate
all recent hospital visits
Reference lab (send outs) not
back yet
Specimen (path) reports
someplace else
Medical Record
Patient doesn't get a good
first visit; Oncologist does not
have all information he needs
to assess patient and
determine course of action
8
7
10
560 Work with Medical Records
to educate.
Include all items ordered on
schedule in "comments"
section.
Start pull/prep process 2
days prior to clinic scheduled
All staff prep/review records
consistently
Computers go down
Schedules and RMC records
not available.
2
5
10
100
Hardware failure
Software failure
Electrical storm/failure
Step
Description
3
Oncologist writes orders for chemo
Occ Det Sev RPN Actions
Failure Mode
Causes
Effects
Orders are incomplete
Oncologist in a hurry
Nurse doesn't review before
he leaves
MD assumes RN knows what
he wants in the blanks
Can't give chemo without
complete orders
Delays to clarify items with
Pharmacy
Long distance phone calls
Reliance on filling in blanks
by telephone order
Adds time to the OPD staff
day
Occ Det Sev RPN Actions
5
8
10
400 Revise orders to be more
user friendly
Orders Illegible (numbers)
Poor penmanship
(Oncologist)
In a hurry
All of the blanks utilize
handwriting and most are for
numbers (amounts) of meds,
fluids, etc.
Medication errors
Patient placed on wrong
cycle/schedule
Delays in therapy to clarify
5
10
10
500 Work with Oncologist to slow
down
Stress legibility of numbers
Reduce number of blanks to
a minimum
Put all orders as templates
on EHR with drop down lists
Patient arrives in OPD for
chemo with no notification
Patient not checked out of
Clinic properly
Communication breakdown
Patient may not get chemo
that day
Outpatient not ready for
patient (staff, resources,
room)
Pharmacy might not have
medication in stock
9
5
5
225 Meeting between OPD and
Clinic staff on that pod
Lack of coordination of care,
testing
Scheduler might not know
patient (consult) might turn
into a chemo
Visit not listed on schedule
(drop in or day of visit
referral)
Scheduling inhouse and out
ofhouse testing is trickey
If information missing,
chemo may be rescheduled
Delay to track down
information
Physician interrupted for
clarification
5
5
5
125
Step
Description
4
Patient may need procedure (port,bone marrow, etc.)
Failure Mode
Causes
Order not written
Clinic procedure room
unfamiliar territory
Effects
Delay
Preop care not coordinated
H&P not done
Instructions not given
Procedure may need a nurse Clinic delays
who doesn't have time on a
busy clinic day
Hospital nurses unfamiliar
with RMC layout
Step
Description
5
Orders written for future labs, chemo cycles, etc.
Failure Mode
Causes
Effects
Staff don't use consistently
Sometimes they're
incomplete
Make copies of original and
make changes to them for
future cycles, testing
Can't tell which is the valid
order
Nursing practicing beyond
scope of practice
Medication errors
Step
Description
6
Oncology patients sent to OPD for chemo, education, etc.
Occ Det Sev RPN Actions
3
5
5
75 Use short form
Schedule through 2B process
2
5
5
50 Always use the same room
at RMC
Take time to orient to room,
equipment
Learn to run the procedure
room
Adjust staffing for some
flexibility
Seek assistance from RMC
MA's, reception
Occ Det Sev RPN Actions
5
7
8
280 Develop new order form
Enforce need for new order
each time no "recycling" to
save time
Failure Mode
Causes
Effects
Room availability
Only have 10 rooms
Also have DayCare surgery
patients
Chemo patient may need
room for an extended time
Poor customer service
2
6
7
84
OPD staff not available for
chemo or education
Patient's cycle requires
weekend cares
Busy shift
Staff unaware patient was
sent over from clinic
Poor customer service
Staff may have overtime if
they come in on weekends
3
6
5
90
Medication error
Required double check not
done in room
Failure to use all 5 R's of
medication administration
Injury to patient
Patient death
2
10
10
200
Chemo exposure in Unit
Setup doesn't include
needleless system when
arrives in unit from
Pharmacy
RN's have to change needles
inside a plastic bag
Potential for sharps injury
Initial chemo prep area near
a food prep area in unit
5
5
10
250 Include Pharmacy in a
discussion/plan session
Injury in area while
giving/receiving service
Inconsistency in way staff
does port draws, chemo
administration, handling of
products and tubing, etc.
Potential for injury is high
2
8
10
160
Dietician not available for
assessment/consult
Dietary referral not made
Patient nutritional needs not
met
7
5
5
175
Step
Description
7
Patients scheduled for future visits, followup
Failure Mode
Causes
Effects
Patient fails to followup with
provider
Inconsistent communication
with patient
Patient complications
Patient unsatisfied with care
Occ Det Sev RPN Actions
Occ Det Sev RPN Actions
5
10
10
500 No results to be given over
the phone
No mechanism for assuring
followthrough
Patients are being given lab
results over phone by
nursing staff
Recommend seeing
physician
Patients reminded they can
receive a copy of their
results with a request to
Medical Records
Calculated Totals
Total Risk Priority Number for the process
Occ: Likelihood of Occurrence (110)
Det: Likelihood of Detection (110)
NOTE: 1 = Very likely it WILL be detected
10 = Very likely it WILL NOT be detected
Sev: Severity (110)
RPN: Risk Priority Number (Occ × Det × Sev)
Annotation
Change: Coordinate with Records
4724
Copy of Oncology/Chemotherapy
The Richland Hospital, Inc.
Richland Center, Wisconsin, United States
HospitalCommunity
Aim: Reduce the RPN for the Oncology Referral/Chemotherapy process in 6 months
Process Data
Date: 03/15/2004
Step
Description
1
Patient referred for Oncology Consult
Failure Mode
Causes
Effects
Patient workup incomplete
for the type of cancer being
seen for
Lack of knowledge of
referring physician.
Patient doesn't get good
information on the first visit.
Needs to scheduled an extra
visit.
Delays patient treatment
Oncologist schedule changes
Walkins
Gets additional patients
scheduled
MD on call in Madison and
needs to leave early
Patient inconvenience
Time is required to change
the schedule staff resources
Step
Description
2
Charts pulled and prepped
Occ Det Sev RPN Actions
10
5
7
2
4
5
350 Arrange a Grand Rounds
Program
Develop referral templates
40
Failure Mode
Causes
Effects
All charts not available for
Oncology clinic
Schedule not complete
Walkins
Referrals day before clinic
Patient information not
available for physician to use
8
7
10
560 Work with Medical Records
to educate staff
Compare charts with
schedule day before
Compare charts with new
schedule day of
All required patient
Referring physician didn't
information not in chart when dictate note yet.
patient seen by Oncologist
Referring physician didn't
write an order for referral.
Medical Records didn't locate
all recent hospital visits
Reference lab (send outs) not
back yet
Specimen (path) reports
someplace else
Medical Record
Patient doesn't get a good
first visit; Oncologist does not
have all information he needs
to assess patient and
determine course of action
8
7
10
560 Work with Medical Records
to educate.
Include all items ordered on
schedule in "comments"
section.
Start pull/prep process 2
days prior to clinic scheduled
All staff prep/review records
consistently
Computers go down
Schedules and RMC records
not available.
2
5
10
100
Hardware failure
Software failure
Electrical storm/failure
Step
Description
3
Oncologist writes orders for chemo
Occ Det Sev RPN Actions
Failure Mode
Causes
Effects
Orders are incomplete
Oncologist in a hurry
Nurse doesn't review before
he leaves
MD assumes RN knows what
he wants in the blanks
Can't give chemo without
complete orders
Delays to clarify items with
Pharmacy
Long distance phone calls
Reliance on filling in blanks
by telephone order
Adds time to the OPD staff
day
Occ Det Sev RPN Actions
5
8
10
400 Revise orders to be more
user friendly
Orders Illegible (numbers)
Poor penmanship
(Oncologist)
In a hurry
All of the blanks utilize
handwriting and most are for
numbers (amounts) of meds,
fluids, etc.
Medication errors
Patient placed on wrong
cycle/schedule
Delays in therapy to clarify
5
10
10
500 Work with Oncologist to slow
down
Stress legibility of numbers
Reduce number of blanks to
a minimum
Put all orders as templates
on EHR with drop down lists
Patient arrives in OPD for
chemo with no notification
Patient not checked out of
Clinic properly
Communication breakdown
Patient may not get chemo
that day
Outpatient not ready for
patient (staff, resources,
room)
Pharmacy might not have
medication in stock
9
5
5
225 Meeting between OPD and
Clinic staff on that pod
Lack of coordination of care,
testing
Scheduler might not know
patient (consult) might turn
into a chemo
Visit not listed on schedule
(drop in or day of visit
referral)
Scheduling inhouse and out
ofhouse testing is trickey
If information missing,
chemo may be rescheduled
Delay to track down
information
Physician interrupted for
clarification
5
5
5
125
Step
Description
4
Patient may need procedure (port,bone marrow, etc.)
Failure Mode
Causes
Order not written
Clinic procedure room
unfamiliar territory
Effects
Delay
Preop care not coordinated
H&P not done
Instructions not given
Procedure may need a nurse Clinic delays
who doesn't have time on a
busy clinic day
Hospital nurses unfamiliar
with RMC layout
Step
Description
5
Orders written for future labs, chemo cycles, etc.
Failure Mode
Causes
Effects
Staff don't use consistently
Sometimes they're
incomplete
Make copies of original and
make changes to them for
future cycles, testing
Can't tell which is the valid
order
Nursing practicing beyond
scope of practice
Medication errors
Step
Description
6
Oncology patients sent to OPD for chemo, education, etc.
Occ Det Sev RPN Actions
3
5
5
75 Use short form
Schedule through 2B process
2
5
5
50 Always use the same room
at RMC
Take time to orient to room,
equipment
Learn to run the procedure
room
Adjust staffing for some
flexibility
Seek assistance from RMC
MA's, reception
Occ Det Sev RPN Actions
5
7
8
280 Develop new order form
Enforce need for new order
each time no "recycling" to
save time
Failure Mode
Causes
Effects
Room availability
Only have 10 rooms
Also have DayCare surgery
patients
Chemo patient may need
room for an extended time
Poor customer service
2
6
7
84
OPD staff not available for
chemo or education
Patient's cycle requires
weekend cares
Busy shift
Staff unaware patient was
sent over from clinic
Poor customer service
Staff may have overtime if
they come in on weekends
3
6
5
90
Medication error
Required double check not
done in room
Failure to use all 5 R's of
medication administration
Injury to patient
Patient death
2
10
10
200
Chemo exposure in Unit
Setup doesn't include
needleless system when
arrives in unit from
Pharmacy
RN's have to change needles
inside a plastic bag
Potential for sharps injury
Initial chemo prep area near
a food prep area in unit
5
5
10
250 Include Pharmacy in a
discussion/plan session
Injury in area while
giving/receiving service
Inconsistency in way staff
does port draws, chemo
administration, handling of
products and tubing, etc.
Potential for injury is high
2
8
10
160
Dietician not available for
assessment/consult
Dietary referral not made
Patient nutritional needs not
met
7
5
5
175
Step
Description
7
Patients scheduled for future visits, followup
Failure Mode
Causes
Effects
Patient fails to followup with
provider
Inconsistent communication
with patient
Patient complications
Patient unsatisfied with care
Occ Det Sev RPN Actions
Occ Det Sev RPN Actions
5
10
10
500 No results to be given over
the phone
No mechanism for assuring
followthrough
Patients are being given lab
results over phone by
nursing staff
Recommend seeing
physician
Patients reminded they can
receive a copy of their
results with a request to
Medical Records
Calculated Totals
Total Risk Priority Number for the process
Occ: Likelihood of Occurrence (110)
Det: Likelihood of Detection (110)
NOTE: 1 = Very likely it WILL be detected
10 = Very likely it WILL NOT be detected
Sev: Severity (110)
RPN: Risk Priority Number (Occ × Det × Sev)
Annotation
Change: Coordinate with Records
4724
