ommon Mistakes In Healthcare FMAs
riginal Healthcare FMA From IHI Website erf eq ffect of ause / Mech of urrent ontrols () & () educe the risk of retained ot separating sponges, sutures when counting Wrong count, last count should be wrong if not counted at first, retained object 9 ot visualizing each individual piece by both circulating &, Being in a hurry, not knowing the policy 3 216 rain new staff & students on correct method of surgical counts ducate staff in department mtgs / skills lab he example above, is a line from an actual Healthcare FMA. Below is a reordering of the same FMA. an you see the differences? All o object left HA lost revenue Worse () to reconcile all post surgery 2 counts () 160 All o object left HA lost revenue Worse () Foreign miscounted 3 counts () 240 object counts (numbered) Add post-surgical hecklist All o object left HA lost revenue Worse () running late counter hurrying 1 counts () 0
riginal Healthcare FMA From IHI Website erf eq ffect of ause / Mech of urrent ontrols () & () educe rrors Administered to wrong patient erious A or death urse failed to verify drug to be administered 2 1 16 raining for all nurses on 5 rights for med. admin. nsure implementation of patient I.. prior to admin. meds. he example above, is a line from an actual Healthcare FMA. Below is a reordering of the same FMA. an you see the differences? Administer medication orrect medication orrect dose orrect patient Admin on time administered to wrong patient Minor iscomfort (6) atient becomes ick (7) HA lost revenue due to non-reimbursed erious A or death () urse failed to verify patient to be administered 2 one () 200 atient monitoring. i.e. blood pressure patient bar coding Administer medication orrect medication orrect dose orrect patient Admin on time administered to wrong patient Minor iscomfort (6) atient becomes ick (7) HA lost revenue due to non-reimbursed erious A or death () o cross- check of patient identification 2 isual () 0 atient monitoring. i.e. blood pressure patient bar coding
riginal Healthcare FMA From IHI Website erf eq ffect of ause / Mech of urrent ontrols () & () Unnecessary Inappropriate recaution isk spread of Infection in the dept. Becomes overwhelmed with unnecessary. precautions, tend to be ignored, necessary ones too. 2 Inadequate assessment info and time to decide. 12 Ask questions in step 1 to protect riage nurse but complete infection control form in step 4 he example above, is a line from an actual Healthcare FMA. Below is a reordering of the same FMA. an you see the differences? Filled out orrect info orrect spelling n time Legible Infection ontrol heet not filled out isk of infection (7) Infection spreading to other areas of hospital (7) isitors become infected () HA lost revenue due to non-reimbursed urse fails to fill out sheet isual () 512 check with checklist Filled out orrect info orrect spelling n time Legible Infection ontrol heet has Incorrect information isk of infection (7) Infection spreading to other areas of hospital (7) isitors become infected () HA lost revenue due to non-reimbursed he patient s chart is mis-read 4 isual () 256 check with checklist
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