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Failure Modes and Effects Analysis (FMEA) Tool

Restraint Reduction

Heartland Behavioral Health Services
Nevada, Missouri, United States
Other
 

Aim: Reduction of Restraint use

Process Data

Date: 11/17/2008

Step Description
1 Patient and family education given regarding restraint/seclusion use and procedure.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Patient and family were not given education regarding restraint/seclusion use and procedure. 1. Patient too agitated to recieve education.
2. Patient too psychotic to understand education.
3. Family unavailable to be educated.
4. No telephone number listed on the chart for family member (s).		 1. Decreased patient and family satisfaction.
2. Patient/family complaints increase because they were not informed of the reason for the restraint/seclusion.
3. Patient remains in restraint/seclusion longer due to lack of education.		 3 5 8 120 1. Review policy/prcedure with staff and ensure that the importance of patient/family education is stressed.
2. Remind staff to document reason for not providing patient and family education during restraint/seclusion use.
Step Description
2 Staff identify environmental factors that may lead to the use of restraint/seclusion.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Staff do not identify environmental factors that may lead to use of restraint/seclusion. 1. High risk settings.
2. Staff not familiar with the residents in their care.
3. Staff not focused on preventative measures for restraint/seclusion.
4. Staff preoccupied with surrounding area.		 1. Escalation of patient's behavior leading to more agitation, threatening/violent behavior.
2. Staff utilizes more restrictive measures than needed.
3. Patient and family/dissatisfaction
4. Other patients may become anxious/agitated leading to oth		 5 7 8 280 1. Assessment and serviellence
2. Reeducation of the staff involved
3. Reassess staffing needs
4. Involve patient and family in training and education process
5. Eliminate environmental factors
Step Description
3 Staff identify behaviors that may lead to need for restraint/seclusion.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Staff does not recognize behaviors that may lead to need for restraint/seclusion. 1. Lack of knowledge
2. Poor assessment skills
3. Poor involvement with the milieu
4. Other distractions on the unit such as (codes, groups, or other decompensating patients).
5. Poor communication among team members during hand-offs.		 1. Patient/staff harm
2. Patient becomes more agitated
3. Situation escalates and become more dangerous to all
3. Disruption of the milieu
4. Other patients become agitated
5. Delay in treatment		 6 7 10 420 1. Staff provides frequent monitoring on all shifts.
2. Faciliate effective hand-off communication at all levels of staff.
3. Assign monitoring schedule for staff with oversight by supervisor.
4. Reassess staffing needs.
Step Description
4 Staff utilize alternative measures prior to using restraint/seclusion.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Staff does not document alternative measures utilized prior to using restraint/seclusion. 1. Attitudes of the staff about restraint/seclusion use.
2. Other distractions on the unit causing delays in documentation.
5. Ineffective communication during hand-offs.		 1. Patient behavior escalates leading to increased anxiety/agitation.
2. Using more restrictive measure than is needed.
3. Patient and family dissatisfaction.		 6 5 8 240 1. Assessment and surviellence.
2. Reeducation of staff involved.
3. Reassess staffing needs.
4. Involve patient and family in training and education process.
5. Improve communication of information during hand-offs.
Step Description
5 Physician order for restraint/seclusion documented.
Failure Mode Causes Effects Occ Det Sev RPN Actions
No physician order documented. 1. Physician unavailable to write the order due to competing priorities.
2. Delay in staff notifying the physician of the situation.		 1. Patient placed in restraint without physician order and physician may not agree with the decision to restrainor seclude the patient. 3 3 10 90 Staff must communicate need for restraint/seclusion to the Physician in a timely manner.
Nurse must oversee staff to ensure compliance with obtaining Physician order for each restraint/seclusion episode.
Step Description
6 Staff monitors the patient throughout restraint/seclusion use.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Staff fails to monitor patient throughout restraint/seclusion use. 1. Inadequate staffing.
2. Inadequate monitoring of staff compliance.
3. Other distractions on the unit causing delays in documentation.		 1. Non-compliance with monitoring of restraint/seclusion policy. 3 3 9 81 1. Staffing Cordinator must ensure that adequate staffing levels are maintained to ensure that staff are able to monitor patients throughout the restraint/seclusion episode.
2. Instruct staff to complete documentation according to policy guidelines.
3
Step Description
7 Assessment/reassessment of patient according to restraint/seclusion policy.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Staff did not assess/ reassess the patient according to the policy. 1. Other distractions on the unit.
2. Lack of staff compliance with policy.		 1. Patient may be experiencing medical problems during restraint/seclusion and staff not aware.
2. Patient remains in a restraint/seclusion longer than necessary.
3. Remaining residents may be unsupervised.		 4 4 7 112 Unit supervisors must oversee staff compliance with policy during each restraint/seclusion episode.
Reeducate the staff on the importance of patient reassessment throughout the restraint/seclusion episode.
Step Description
8 Patient's basic needs met throughout the time patient remains in restraint/seclusion.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Patient's basic needs (ADLs, circulation assessment, skin assessment, respiratory status) not met throughout the restraint/seclusion episode. 1. Delay in documentation due to other concurrent distractions on the unit.
2. Patient too agitated to cooperate with process.		 1. Patient's basic needs not met leading to poor hygeine, dehydration, poor circulation, other medical complications.
2. Decreased patient/family satisfaction
3. Asphexiation
4. Patient caused injury in seclusion		 3 5 10 150 1. Plan adequate staffing so that basic needs of patients are met throughout restraint/seclusion episode.
2. Nurse/Staff leader must monitor staff compliance with policy.
Step Description
9 Liscenced professional completed face to face assessment within 1 hour of the restriction.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Liscenced Professional did not complete face to face assessment within 1 hour of application of restriction. 1. Liscenced Professional not available to complete the assessment.
2. Delay in staff/nurse informing the Liscenced Professional about application of restraint/seclusion.		 1. Failure to comply with policy.
2. Less restrictive alternative not utilized.		 7 8 10 560 1. RN/LPN must notify the Liscenced Professional asap when restraint/seclusion are applied.
2. Least restrictive alternatives must be documented.
3. Contact back-up Liscenced Professional whenever the first professional couldn't be contacted.
Step Description
10 Patient demonstrates the ability to function safely prior to discontinuing restraint/seclusion.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Patient remains in restraint/seclusion longer than necessary. 1. Lack of timely assessment of patient's behavior.
2. Delay in removal of restraint/seclusion due to other distractions on the unit.		 1. Decreased patient/family satisfaction.
2. Poor utilization of staffing resources.
3. Injury occurs due to prolonged restraint/seclusion.		 2 5 10 100 1. Reeducate staff on policy for removal of restraint/seclusion.
2. Unit Supervisor must oversee staff compliance during each restraint/seclusion episode.
Step Description
11 Restraint/seclusion discontinued when the patient no longer needs restriction.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Patient restrained or secluded longer than necessary. 1. Lack of timely assessment by staff.
2. Non-compliance with restraint policy.		 1. Decreased patient/family satisfaction.
2. Poor utilization of staffing resources.		 2 8 10 160 1. RN/LPN must assess patient according to policy guidelines.
2. Nurse must oversee staff compliance for each episode of restraint use.
3. Review with the staff importance of removing restraint/seclusion when they are no longer needed.
Step Description
12 Restraint/seclusion reordered by the physician every hour.
Failure Mode Causes Effects Occ Det Sev RPN Actions
Restraint/seclusion not reordered every hour. 1. Physician non-compliance with policy.
2. Staff did not communicate patient's status in a timely fashion.		 Patient restraint/seclusion order expired while patient in restraint/seclusion.
Patient remains in restraint/seclusion longer than necessary.
Poor utilization of staffing resources.		 3 7 10 210 All restraint/seclusion orders must be reviewed by the Physician daily.
Unit Supervisor must monitor staff compliance daily.

Calculated Totals
Total Risk Priority Number for the process 2523

Occ:   Likelihood of Occurrence (1-10)
Det:   Likelihood of Detection (1-10)
 
NOTE:  1 = Very likely it WILL be detected
 10 = Very likely it WILL NOT be detected
Sev:   Severity (1-10)
RPN:   Risk Priority Number (Occ × Det × Sev)

Annotation
None