Process Failure Mode Effect Occurrence Detection Severity RPN Actions Step Rating Rating Rating Leadership Inadequate Lack of Case managers/ 4 7 6 168 Ensure that all unit and support of support from knowledge of discharge system leaders are program individual unit the program planners are not aware of program. leaders and on board and Educate on the system leader accountability is programs ability to over case not followed decrease readmissions managers/ through on with and falls in the home discharge case managers/ setting. planners discharge planners Patient Patients do not Fear of At risk for 6 8 9 432 Education must occur Reporting report when a reporting/ loss subsequent and patients must fall without of where injury understand the injury occurs independence could occur as importance of reporting in the home well as falls, as subsequent falls could result in injury with permanent damage ROOT CAUSE ANALYSIS DIAGRAM Misuse/not using walking devices Appropriate Footwear Polypharmacy Fear of falling Inadequate lighting High Risk Medications Poor Balance Tripping hazards Knowledge of Medication Confusion/altered mental status Outdoor walkways Taking Medications as prescribed
Process Step Failure Mode Effect Occurrence Rating Detection Rating Severity Rating RPN Actions Leadership support of program Inadequate support from individual unit leaders and system leader over case managers/ discharge planners Lack of knowledge of the program Case managers/ discharge planners are not on board and accountability is not followed through on with case managers/ discharge planners 4 7 6 168 Ensure that all unit and system leaders are aware of program. Educate on the programs ability to decrease readmissions and falls in the home setting. Patient Reporting Patients do not report when a fall without injury occurs in the home Fear of reporting/ loss of independence At risk for subsequent where injury could occur as well as 6 8 9 432 Education must occur and patients must understand the importance of reporting falls, as subsequent falls could result in injury with permanent damage ROOT CAUSE ANALYSIS DIAGRAM Misuse/not using walking devices Appropriate Footwear Polypharmacy Fear of falling Inadequate lighting High Risk Medications Poor Balance Tripping hazards Knowledge of Medication Confusion/altered mental status Outdoor walkways Taking Medications as prescribed