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Med Safety Module 2
Terms in this set (22)
What is Root Cause Analysis used for?
To identify the critical underlying reasons for the occurrence of an adverse event or close call (near miss).
What questions are asked in Root Cause Analysis (RCA)?
Why did it happen?
What will prevent it from happening again?
What is Failure Mode Effect Analysis (FMEA)?
A systematic, proactive method for evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.
What are the 5 steps of the FMEA process? "DAG CI"
1. Define the topic
2. Assemble the team
3. Graphically describe the process
4. Conduct the analysis
5. Identify actions and outcome measures
FMEA is a(n) (individual/team) tool.
What are the methods used in "Step 3. Graphically Describe the Process"?
A. Develop and Verify the Flow Diagram (this is a process vs. chronological diagram)
B. Consecutively number each process step identified in the process flow diagram
C. If the process is complex, identify the area of the process to focus on (manageable bites)
D. Identify all sub processes under each block of this flow diagram. Consecutively letter these sub-steps.
E. Create a flow diagram composed of the sub processes
What methods are followed in "Step 4. Conduct a Hazard Analysis"?
A. List Failure Modes
B. Determine Severity & Probability
C. Use the Decision Tree
D. List all Failure Mode Causes
What methods are followed in "Step 5. Actions and Outcome Measures"?
A. Decide to "Eliminate," "Control," or "Accept" the failure mode cause
B. Describe an action for each failure mode cause that will eliminate or control it.
C. Identify outcome measures that will be used to analyze and test the re-designed process
D. Identify a single, responsible individual by title to complete the recommended action.
E. Indicate whether top management has concurred with the recommended actions
In Probability of Detection Scores, what is a Remote score?
Unlikely to be detected (may happen in 5-30 years)
In Probability of Detection Scores, what is an Uncommon score?
Possible to detect (may happen sometimes in 2-5 years)
In Probability of Detection Scores, what is an Occasional score?
Probably will detect (may happen several times in 1-2 years)
In Probability of Detection Scores, what is a Frequent score?
Likely to detect immediately or within a short period (may happen several times in 1 year)
In Probability of Occurrence Scores, what is a Frequent score?
Likely to occur immediately or within a short period (may happen several times in 1 year)
In Probability of Occurrence Scores, what is an Occasional score?
Probably will occur (may happen several times in 1-2 years)
In Probability of Occurrence Scores, what is an Uncommon score?
Possible to occur (may happen sometimes in 2-5 years)
In Probability of Occurrence Scores, what is a Remote score?
Unlikely to occur (may happen in 5-30 years)
In Severity Scores, what is considered Catastrophic?
Death or major permanent loss of function, suicide, rape, hemolytic transfusion reaction, surgery or procedure on the wrong patient or wrong part of body, infant abduction or discharge to wrong family
In Severity Scores, what is considered Major?
Permanent lessening of bodily function (sensory, motor, physiological, or intellectual), disfigurement, surgical intervention required, increased length of stay for three or more patients, increased level of care for three or more patients
In Severity Scores, what is considered Moderate?
Increased length of stay or increased level of care for one or two patients.
In Severity Scores, what is considered Minor?
No injury, nor increased length of stay, nor increased level of care.
How is the Hazard Score calculated and evaluated?
The product of the severity and probability scores:
Severity X Probability of Occurrence X Probability of Detection = Hazard Score (RPN)
What are the 4 questions in the Decision Tree?
1. Does this hazard involve a sufficient likelihood of occurrence and severity to warrant that it be controlled? (e.g. Hazard Score of 160 or higher)
2. Is this a single point weakness in the process? (e.g. failure will result in system failure) (Criticality)
3. Does an Effective Control Measure exist for the identified hazard?
4. Is the hazard so obvious and readily apparent that a control measure is not warranted? (Detectability)
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