NR533: Quality Improvement and Patient Safety

PLEASE SEE THE ATTACHMENT FOR DETAILED INSTRUCTIONS

Week 06 Assignment – Failure modes and effects analysis (FMEA)

Purpose:

This assignment provides students with the opportunity to identify a high-risk process in the practice setting and then conduct a failure modes and effects analysis (FMEA).

The FMEA is a systematic, proactive approach to assess risk of failure and harm in a high-risk process, and identify areas for process improvement.

   

PLEASE SEE ATTACHMENT FOR THE CHART

• Use the FMEA Table as displayed in Figure 1 at the end of Week 5 lesson. A copy of the table is also available in an Excel Spreadsheet.
• Steps in the process
• Failure modes, failure causes, and failure effects
• Likelihood of Occurrence (1-10)
• Likelihood of Detection (1-10)
• Severity (1-10)
• Risk Profile Number (RPN)
• Actions to Reduce Occurrence of Failure

Instructions:

1. Use the MS Excel table FMEA for High Risk Process to fill out your failure and effect analysis according to the IHI lesson.
2. Attach your Excel table below and ‘submit for grade’.

  

Week 6: Required Readings

• Nash, Joshi, Ransom, & Ransom: Chapter      10.
• Chassin, M. R., & Loeb, J. M.. (2011, April). The ongoing quality improvement journey: Next      stop, high reliability. Health Affairs, 30(4), 559-568. (Library Link)
• TJC. (2021). 2021 National Patient Safety Goals. The Joint Commission.
• Staines, A., Amalberti, R., Berwick, D.M., Braithwaite, J., Lachman, P., & Vincent, C. A.. (2020). Covid-19: Patient Safety and Quality Improvement skills to deploy during the surge. International Journal for Quality in Health Care, pp 1-3.
• Thull-Feedman, J., Mondoux, S., Stang, A., & Chartier, L.B. (2020). Going to the COVID-19 Gemba: Using observation and high reliability strategies to achieve safety in a time of crisis. Canadian Journal of Emergency Medicine, 2020,      1-4.
       (Open Access Creative Commons NC-4.0)

Content in weeks Lesson

• Federico, Frank. (2017). Bringing it all together: The journey to high reliability. Barnes Jewish      Hospital; Washington University in St. Louis Physicians. (Video)
• Federico, Frank. (2021). Reliable Systems and Processes. IHI Open School. (Video)
• MedStar Health. (2017, Sept.). Mindfulness in a High Reliability Organization. MedStar Health. (Video)
• N.A. (2018, June). Understand the Science of Safety. Agency for Healthcare Research and      Quality. (Video)
• N.A. (2021). Transforming Health Care into a High Reliability Industry. Joint Commission      Center for Transforming Healthcare. (Video)
• Press Ganey Associates. (2018, Feb.). High Reliability: Improving the Safety, Quality and      Experience of Care. Press Ganey Associates, LLC. (Video)

Sheet

1

Failure Modes

and Effects

A

nalysis

Name of High Risk Process:

Steps in the Process

Failure Modes

Failure Causes Failure Effects Likelihood of Occurrence (1-10) Likelihood of Detection (1-10) Severity (1-10) Risk Profile Number (RPN) Actions to Reduce Occurrence of Failure 1

2

3

4

5 Total RPN Notes: Failure Mode: What could go wrong? Failure Causes: Why would the failure happen? Failure Effects: What would be the consequences of failure? Likelihood of Occurrence: 1-10 (10 = very likely to occur) Likelihood of Detection: 1-10 (10 = very unlikely to detect) Severity: -10 (10 = most severe effect) Risk Priority Number (RPN): Likelihood of Occurrence x Likelihood of Detection x Severity Reference: Institute for Healthcare Improvement (2017). QI essentials toolkit: Failure modes and effects analysis (FMEA) tool.

1
2
3
4
A

B

Name of High Risk Process:

Failure Modes and Effects Analysis

Week 06 Assignment – Failure modes and effects analysis (FMEA)

Purpose:

This assignment provides students with the opportunity to identify a high-risk process in the practice setting and then conduct a failure modes and effects analysis (FMEA)

.

The FMEA is a systematic, proactive approach to assess risk of failure and harm in a high-risk process, and identify areas for process improvement.

Criteria	Item Description
Title	· Title indicates a high-risk process for a FMEA.
High-Risk Process	· Describe in a single paragraph the high-risk process and rationale for selecting the process.
Process Map/Flowchart	· Create a process map or flowchart to describe the steps in the high-risk process. Recommend a PowerPoint slide to depict the steps in the selected process.
FMEA Table	· Use the FMEA Table as displayed in Figure 1 at the end of Week 5 lesson. A copy of the table is also available in an Excel Spreadsheet. · Steps in the process · Failure modes, failure causes, and failure effects · Likelihood of Occurrence (1-10) · Likelihood of Detection (1-10) · Severity (1-10) · Risk Profile Number (RPN) · Actions to Reduce Occurrence of Failure

Instructions:

1. Use the MS Excel table 

FMEA for High Risk Process
 

to fill out your failure and effect analysis according to the IHI lesson.

2. Attach your Excel table below and ‘submit for grade’.

Refer to the 

Syllabus

 for point value of this assignment. Your Activity Completion checkbox will be marked when you submit to this dropbox, remember to check your gradebook for your grade.

Week 6: Required Readings

·

Nash, Joshi, Ransom, & Ransom

: Chapter 10.

· Chassin, M. R., & Loeb, J. M.. (2011, April). 

The ongoing quality improvement journey: Next stop, high reliability.

 Health Affairs, 30(4), 559-568. (Library Link)

· TJC. (2021). 

2021 National Patient Safety Goals

. The Joint Commission.

· Staines, A., Amalberti, R., Berwick, D.M., Braithwaite, J., Lachman, P., & Vincent, C. A.. (2020). 

Covid-19: Patient Safety and Quality Improvement skills to deploy during the surge.

 International Journal for Quality in Health Care, pp 1-3.

· Thull-Feedman, J., Mondoux, S., Stang, A., & Chartier, L.B. (2020). 

Going to the COVID-19 Gemba: Using observation and high reliability strategies to achieve safety in a time of crisis.

 Canadian Journal of Emergency Medicine, 2020, 1-4.
(Open Access 

Creative Commons NC-4.0

)

Content in weeks Lesson

· Federico, Frank. (2017). Bringing it all together: The journey to high reliability. Barnes Jewish Hospital; Washington University in St. Louis Physicians. (Video)

· Federico, Frank. (2021). Reliable Systems and Processes. IHI Open School. (Video)

· MedStar Health. (2017, Sept.). Mindfulness in a High Reliability Organization. MedStar Health. (Video)

· N.A. (2018, June). Understand the Science of Safety. Agency for Healthcare Researcha and Quality. (Video)

· N.A. (2021). Transforming Health Care into a High Reliability Industry. Joint Commission Center for Transforming Healthcare. (Video)

· Press Ganey Associates. (2018, Feb.). High Reliability: Improving the Safety, Quality and Experience of Care. Press Ganey Associates, LLC. (Video)