Physical Therapy Fall Prevention

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9/14/2015

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)

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=16974&ScenarioId=19187&Type=1

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9/14/2015

Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report

Annotation
None 

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=16974&ScenarioId=19187&Type=1

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