Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
Failure Modes and Effects Analysis (FMEA) Tool
Physical Therapy Fall Prevention
Sells Indian Health Service Hospital
Sells, Arizona, United States
HospitalCommunity
Aim: To decrease outpatient falls by 50% in 12 months
Process Data
Date: 02/19/2014
Step
Description
1
Outpatient enters facility
Failure Mode
Causes
Effects
Admin staff at front desk
cannot determine fall risk
No assessment tool or
education for clerical and
adminsitrative staff
No fall risk assigned to
patients
Step
Description
2
Patient fills out outome measures for specific referral problem
Failure Mode
Causes
No info taken from patient
No tool for risk assessment
specifically regarding fall risk for patients presenting with
gait device issue only.
Effects
Patients referred for canes
go unassessed for fall risk
Step
Description
3
Patient sits in waiting room and waits to be called in by thereapist for
evaluation and treatments
Step
Description
4
Patient enters clinical treatment area
Failure Mode
Causes
No assessment of fall risk
during evaluation
Failure of staff to use an
Patients at risk for fall go
approipriate risk assessment unassessed
tool
Step
Description
5
Patient leaves treatment area
Failure Mode
Causes
Patient not identified as a fall No fall risk tool employed
risk
Effects
Effects
High risk of fall at home or in
the clinic
Occ The Yourself RPN Actions
5
4
10 200 Initiate screening tool to
all patients coming for
ambulation devices
without order for
physical therapy
balance program
Occ The Yourself RPN Actions
10
1
10 100 Any patient referred to
PT for cane or crutch
issue will fill out a brief
questionnaire detailing
if they have had falls in
the last year and if so,
how many and what
was the injury thewy
sustained. yes answers
will prompt message to
primary care doctor
Occ The Yourself RPN Actions
4
9
10 360 All patients with
outpatient Diagnosis of
difficulty walking or
weakness get screened
with a balance
assessment tool such as
the Tinetti, Berg
balance or Get up and
go tool.
Occ The Yourself RPN Actions
10
5
10 500 All patient who are at
risk for fall by virtue of
their risk factors
present and the reason
for referral get
screened by a therapist.
Patients referred for
issue of gait device get
screened by
administrative staff with
questionnaiire that
alerts PT to co
Calculated Totals
Total Risk Priority Number for the process
1160
Occ:
It:
Likelihood of Occurrence (110)
Likelihood of Detection (110)
NOTE: 1 = Very likely it WILL be detected
10 = Very likely it WILL NOT be detected
Yourself: Severity (110)
RPN:
Risk Priority Number (Occ × Det × Sev)