Slide 12

Project RED: Module 4: Re-Engineering Patient Discharge: The Hospital

Provides a four-module training program to help hospitals implement Project RED.

Double Check for Failure Modes

  • Omission.
  • Excessive repetition.
  • Wrong sequence.
  • Early or late execution.
  • Incorrect identification or selection.
  • Incorrect information.
  • Incorrect counting or calculating.
  • Overlooking.
  • Misreading or misunderstanding.
  • Incorrect decision.
  • Incorrect transcription.
  • Incorrect route, position, or setting.

Notes:

These research-based failure modes have been identified in health care. When designing new processes, double check for these failure modes across the new tasks and activities:

  • Omission — What part of the process is prone to be omitted?
  • Excessive repetition — What part of the process is prone to be excessively repeated?
  • Wrong sequence — In what wrong sequence can the process be executed?
  • Early or late execution — What execution can be early or late?
  • Incorrect identification or selection — What object (patient, medication, equipment) of the sub-process is prone to be selected or identified incorrectly?
  • Incorrect counting or calculating — What objects of the process can be counted, measured, or calculated incorrectly?
  • Overlooking — What information, risk, failure, or error is prone to be overlooked?
  • Misreading or misunderstanding — What misunderstanding or misreading is prone to occur?
  • Incorrect decision — What incorrect decision is prone to occur?
  • Miscommunication — What miscommunication is prone to occur?
  • Incorrect transcription or entering — What transcription or data entry error is prone to occur?
  • Incorrect route, orientation, position, or setting — What route, orientation, position, or setting error is prone to occur?

Additional failure modes seen in health care include:

  • Hazardous movement — What movement can cause harm (slipping, falling, etc.)?
  • Not available — Who or what is prone not to be available?
  • Hardware failure or incorrect information — What hardware failure or incorrect information provision is prone to occur?
  • Unexpected patient reaction — What unexpected patient reaction is prone to occur?

By reviewing each process step within your map and walking through these questions, you might find that there are still failure modes within the defined process. This analysis will ensure that you have done all that you can to eliminate failures in the future state process.

Page last reviewed August 2011
Internet Citation: Slide 12: Project RED: Module 4: Re-Engineering Patient Discharge: The Hospital . August 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/module4/slide12.html