OBJECTIVES: The overall aim was to identify the modes of failure that impacted the practice outcomes relating to pressure ulcer prevention. The group then focused on establishing goals to reduce hospital acquired pressure ulcers by 50 percent in 6 months and 100 percent in 12 months.
OUTCOMES FMEA is a proactive risk assessment process for examining possible ways in which failure can occur. It includes identification of potential mistakes to determine whether the consequence of those oversights would be acceptable or unacceptable. The process assumes that no matter how careful or knowledgeable people are errors will likely occur. The focus is therefore not reactive but a proactive response.
The failure modes identified were communication of the patient’s pressure ulcer risk status and the inconsistencies in nursing practice in completing accurate Braden and Skin assessments. The action taken to reduce the failure modes was through education. The interventions included a computer base learning module and an RN and Support Staff skill’s fair as well as an RN – Pre-Test on pressure ulcer knowledge on Survey Monkey. A plan for monitoring the process improvements will include a pressure ulcer knowledge post test, development and implementation of a tracking tool for hospital acquired pressure ulcers and auditing Braden and skin assessment documentation.
Implementing these process improvement strategies, it is anticipated that the goals at this community hospital will be achieved.