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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