Thanks to visit codestin.com
Credit goes to www.scribd.com

Scribd
Upload
73 views22 pages

Failure Modes Events Analysis: DR Tai Hwei Yee DCQO, National Healthcare Group ACMB (Clinical Quality & Audit), TTSH

This document provides an overview of failure mode and effects analysis (FMEA). FMEA is a tool used to improve system performance by identifying potential failures, their causes and effects, and methods to address failures. The key steps in performing an FMEA are to define the scope, failure modes, causes, effects, associated risks, and corrective actions. FMEAs can be used to examine failures in design, processes, and other areas. They help reduce risks and costs while improving safety, quality and accountability. Common pitfalls include not properly defining the scope, mixing up different failure aspects, including the wrong participants, and failing to implement solutions identified through the analysis.

Uploaded by

chethan626
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
73 views22 pages

Failure Modes Events Analysis: DR Tai Hwei Yee DCQO, National Healthcare Group ACMB (Clinical Quality & Audit), TTSH

This document provides an overview of failure mode and effects analysis (FMEA). FMEA is a tool used to improve system performance by identifying potential failures, their causes and effects, and methods to address failures. The key steps in performing an FMEA are to define the scope, failure modes, causes, effects, associated risks, and corrective actions. FMEAs can be used to examine failures in design, processes, and other areas. They help reduce risks and costs while improving safety, quality and accountability. Common pitfalls include not properly defining the scope, mixing up different failure aspects, including the wrong participants, and failing to implement solutions identified through the analysis.

Uploaded by

chethan626
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 22

Failure Modes Events Analysis

Dr Tai Hwei Yee DCQO, National Healthcare Group ACMB ( Clinical Quality & Audit), TTSH

Failure Mode
Manner in which a System Fails

FLYER DRAMA

173 rescued after being stranded in capsules for several hours.

Its hard to imaging something so small could have stopped the Singapore Flyer, which dominates the Marina Bay Skyline

Jan 9, 2009 The New Paper

What could have been done better


Response time for Dive Marine to arrive on the scene was not fixed in the SOP for evacuation Who should be called in if such an incident happened again Chain of command and responsibilities to be worked out between Dive Marine, Police and SCDF Use of Auto Descenders Length of Rope increased from 200 to 300m Food supplies, Portable commodes and blankets in each capsule

What we will cover today .


1. 2. 3. 4. 5. What is FMEA How can FMEA help us How is an FMEA done Examples as we go along Limitations and pitfalls of FMEA

Failure Modes Events Analysis


Tool to improve system performance by identifying effects of potential product or process failure methods to eliminate or reduce chances of failure

Design FMEA
Examines function of component or part of system or system e.g. incorrect material selection

Process FMEA
Examines process used to make component, part or the whole system e.g. incorrect method of assembling materials

Why FMEA
Product Development Quality Improvement Patient Safety Requirement (JCI /JCAHO) Preventative

What can FMEA do for you?


Reduce actual or potential failures Reduce complaints / claims Reduce operating costs Promote accountability Improve teamwork Provide follow through

Steps in Performing FMEA


Define Focus and Scope Define Failure Mode Identify Cause of Failure Identify Effects of Failure Determine Risks of Failure Corrective Actions

What areas to focus on?


High risk areas recommended by JCAHO
Medication Usage Operative and other procedures Resuscitation Use of Blood and Blood products Restraints High risk populations Seclusion

Define Failure Mode


Construct a detailed flow chart of the process Multi-disciplinary inputs from staff involved in process Determine which step and the number of ways in which it can fail
Dr writes order Nurse sends order Order is dispensed Patient given drug

Order is Illegible Wrong dose ordered Order is incomplete

Misread abbreviation Transcribed wrongly Did not notice order

Define Failure Mode


Man Method Machine Material Environment

Causes of Failure Mode


Use Root Cause Analysis Ask Why, Why, Why, Why, Why .. 5 times

Dr rushed through orders Short-handed due to poor leave planning

Poor Handwriting Legibility not emphasized during orientation Misread Handwriting No policy or procedures Lack of pre-printed order sets

Dim Lighting at the nursing counter

Effects of Failure
Immediate consequence consequences Local Effect End effect cumulative

Risks of Failure
Occurence
Likelihood of failure by a specified cause Scale of 1-10; 1=failure unlikely to 10=failure certain

Severity
The impact of failure Scale of 1-10; 1=no/slight effect to 10=mostsevere/death

Detection
How early can we detect and correct failure Scale 1-10; 1=very highly likely detected to 10=almost certain not to detect

Risk Priority Number (RPN)


Compounds occurance, severity and likelihood of detection Helps us to prioritise area of greatest concern RPN = occurance x severity x detection
rating rating rating

Corrective Actions
Should be taken when
Severity rating is 9 or 10 Severity rating x Occurance rating is high RPN is high No absolute number for high RPN

Solutions
1. 2. 3. 4. 5. Avoid or eliminate failure mode Make failure more easily detectable Reduce/ mitigate severity of impact Who is responsible for the solution? By when is the solution to be implemented

Limitations
Resource intensive Missing key failures
Limited understanding of human error Focus on single event initiating failure mode Focus on external influence limited

Common Pitfalls in doing an FMEA


Dont understand scope and method Fail to separate Failure mode, cause and effect Wrong participants Requires honesty and openness from team Not identifying solutions to problems

No follow-up action

Thank you
Questions?

You might also like