Question

Define and apply FMEA steps in relationship to the PDSA cycle concerning improving patient safety and reducing medical errors in a large hospital system. Be specific and give examples.

Answer 1

Define the plan - Do study - Act- 0 0 0 + Stage 1:- Plan :- Identify an opportunity and plan for impro- Vement ay Assemble the team or cong r e by Create an aim statement e Examine the current approach Wald oro fx Identity ity Potential solution potential solution. lorod hone Do i stast carrying out your plan om t e rest the theory for improvement prill by carry out the plan yu're develop ex collect, chart and display data. but Document Problems, unexpected obseoration, side ettects Study - out examine your results Examine your resu ay bid the result match the theory predictions. by Are there trends, unintended side etteets? c) Is there an improvements a - - Соинице tо ехо им е од - еха и тие бих Process using the PDSA cycle, by standardizing the improvement or developing a new theory, and es- tablishing future plans. Com Z PDSA and medication Errors - Plan → doprow onurg rot rohlorobiuras ay The team (Root cause analysis team) bow by (Aim statement) - Decrease potential over dosing of medication lessons when pharmaly is closed. cy current approach any nurse allwed to override after pharmacy houssed 11pm-6am. sh ix overrides are entered on the PIXIS systen nurse üx this process does not require a double check system making room for restors. inx change arailable dosing to matching most common dose eg. Hydomorphone current available la = 4 mal via (CT ( = 4y

RN to double check during o required Require a nurse I must be RN to do any override atter pleormary, nours mot By This requirement is also required day di ay during pharmacy nours during os Graumal wie Policy states any overrides during Phongo ( must be valerated by emergenti > change arailable dosing et Hydroms match most common dosing : 1 mg/ Pulling multiple vials should alwa to use Study: 192 ax Phormaey receives printout et all et Hydromorphone to flag Ple vials should always be 3. printout of all overrides reriewed with actual A validate if appropriate over order / situation to validate if appro ride. - Prepon by Review all medication errors and repor No related to overrides. ② Act :- Potential systematically idently sis (FMEA) is a> Nurse manger notified or any discrepancies in Practices. .. by Any medication errors and a resull- et overside continued to monitored for additional at condideration for process changen. - nola Failure mode and eltees analysis (FMEA) is. used to systematically identifyed areas ats potential failure within a process and range, what the elects would be before the an actual enor take place. This protee fire Process can be used before new medication are prescribed, purchased, dispended and administered so that, Petrchased mptive action can or be taken to How eliminate, or mitigate any potential Patient hormon Steps & ax Stept: create a detailed diag et the process and tasks involved with storing and dispensing the new produe Explore how the intended produed w be prescribedo new product. oro dued would

How would the prescription be received) who would prescribed it, and for which patients what clinical Patient information would be needed before it is prescn bed or dispensed? Step2 :- Identity hood and where systems and processes may fails and what could go wrong while consi- denng how the product would be used. Step 3 - For each failure mode, determine the likelihood of making an essor as well as the potential conse- quences of the tailures. How often could this tailure mode ocor? What would happen to the patient if the drug were given in the wrong dose, at the wor wrog Drong time, or by the wrong not route? Steb , 0 0 Step 4 - considere the severity of the outcome, and identify any preexisting processes that could help eliminated or detect the error before it reaches. the patient Step 5 - Develop action to prevent the enors, detect it before it reaches the patients, or minimize it consequences if failure modes reved errors with significant consequeces.