6243 USE of the FAILURE, MODE, EFFECTS, Annalysis (FMEA): A QUALITY Improvement PROCESS to Decrease HOSPITAL Acquired Presure Ulcers In A COMMUNITY HOSPITAL

Jeanne M. Stadler, MS, RN, CWOCN, Community Memorial Hospital, Nurse Specialist Wound, Ostomy and Continence, Menomonee Falls, WI and Shawneen Schmitt, MSN, MS, RN, CWOCN, CFCN, Community Memorial Hospital, Nurse Specialist Wound, Ostomy, Continence, Menomonee Falls, WI
PURPOSE:    Every year the Patient Quality and Safety Committee at this community hospital (250-beds acute care) selects a process improvement project to meet the requirements of The Joint Commission.   Decreasing hospital acquired pressure ulcers was the project chosen for 2011.  A WOCN acted as the team leader for the project and an experienced FMEA facilitator assisted the team in using the tools specific for this quality improvement process that included a multidisciplinary team.

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.