involved with the process. All participants will not need to participate in the entire process, but all will need to be included in the discussions with the steps that they are involved in. Step 3: The team will list all the steps within the process. The team then evaluates, establishes and agree upon the list of the steps. Step 4: The team will complete the FEMA table that has numbered steps. The list includes: 1. Failure mode where the team lists everything that could possibly go wrong during the process. 2. Make a list with all possible causes that you identified asking why would the failure happen? Failure causes. 3. Failure Effects step is where the team will list all possible adverse events for each failure mode. 4. On a numbered scale of 1-10 with 1 being the least likely to happen, what is the number that this event will occur? Likelihood of occurrence 5. Likelihood of detection. Also, on a number scale of 1-10 where 10 is the is likely not detected. 6. Severity on a 1-10 scale with 10 being most likely of the severe harm occurring. 7. Risk Profile is where each failure mode gets a score. Multiply the three scores from above that the team identified. 8. Actions to reduce occurrence failure. Listing al possible actions that improve the safety systems with the highest risk profile.
8 Step 5: Use the risk profile numbers to plan a improvement effort. Use the FEMA plan actions to decrease harms resulting from the failure modes. The team should first consider the top 10 highest risk profile numbers as the opportunities for improvement. C2. FMEA Table Submitted the table in a separate document. D. Intervention Testing I would apply the four stage problem solving model plan-do-study-act. I would test the interventions from my improvement plan to see if sedation death rates are decreasing. To evaluate if our plan is working, I would gather data such as chart audits on checklist compliance, sedation death rates, analysis of protocol compliance to death rate ratios. I would share this data with staff to show the improvement. During the pilot I would monitor compliance and noncompliance of sedation module completion and sedation validation check offs that improve care. E. Demonstrate Leadership Promoting quality care is the foundation of a bedside nurse. A professional nurse is important in their role in promoting quality and quality outcomes as they are at the bedside assessing and observing patients. The nurse is the one who practices protocols and standard at the bedside. A leader should engage staff in patient safety, and quality patient centered care. Being the leader of a medical surgical unit in the past I will share some examples. Participating unit daily safety huddles that discuss any safety issues to include, falls, indwelling urinary catheters, readmissions, staffing and Peripheral inserted central lines. Completing annual skills fairs and online education modules related to quality outcomes would also promote quality care.
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- Winter '20
- DARLENE MCCOMBS
- Failure mode and effects analysis, RCA