Table 3 Examples of identified failure modes illustrate actual or potential failure modes
From: Documentation framework for healthcare simulation quality improvement activities
Failure mode (identified barrier) | Impact | Outcome |
|---|---|---|
Position of A/C power cord to cancer care treatment chairs demonstrated significant falls risk to the patient and staff. Also inhibitive of efficient staff workflow | Safety Patient experience Efficiency | Each treatment pod had additional power point installed and TV’s repositioned in each pod |
No standing orders for adrenaline administration in an emergency (no resuscitation team onsite) | Safety | Organisational Resuscitation Committee endorsed standing orders for the hospital for all registered nurses to administer adrenaline in a medical emergency |
Imminent birth presenting to reception (no emergency department) No wheelchair or trolley at front reception to move patient to another location No neonatal resuscitation equipment available Unknown process—unknown if oxytocic medications are/will be available from pharmacy | Safety Efficiency Patient experience | Required equipment purchased and staff orientated to its location and function Pharmacy consulted and process implemented |
Adult (chest pain) and a paediatric (asthma) presenting to front reception With one administration staff on front desk, cannot initiate required phone calls at the desk to get help and attend to patient Insufficient emergency equipment located on reception level of the hospital Support services assistant and security currently not on medical emergency page (security: external company) Staff knowledge in management of a paediatric emergency or first aid measures (no paediatric inpatients for this hospital) | Safety Efficiency Patient experience | Recommendations implemented: Staff assist button for front reception Mobile phone/deck phone at reception External security company to be added to the emergency pager list Emergency equipment purchased for reception: - Oxygen and masks (adult and paediatric) - AED - Vital signs monitor - PPE - IV cannulation Paediatric education plan and resuscitation training planned and commenced |
Volume of overhead emergency buzzer in inpatient areas. Staff in single rooms with door closed cannot hear staff assist or code blue call bells | Safety Efficiency | Company contacted and volume increased |