Failure Mode and Effect Analysis

Project – Minimizing the Risk of

Infant Abduction.
Acknowledgment:

We would like to extend our thanks to the FMEA team member, for their valuable input, dedication
motivation and creativity of their ideas.

Background:

Infant abduction is a serious healthcare security issue once occurred; it can impact the organization
reputation and cause severe harm to the infant family. There is no valid national statistics source
available about hospital infants’ abduction. However, the problem is well known in the media and
many cases occurred in Jeddah and other cities. That led the ministry of health to apply electronic
infant bracelet as a security measure.

FMEA:

Failure Modes and Effects Analysis (FMEA) is a systematic, proactive method for evaluating a process
to identify where and how it might fail and to assess the relative impact of different failures, in order
to identify the parts of the process that are most in need of change.

FMEA includes review of the following:

1- Steps in the process.

2- Failure modes (What could go wrong?).
3- Failure causes (Why would the failure happen?).
4- Failure effects (What would be the consequences of each failure?).

FMEA Scoring System:

Severity Rank Description

10 Hazardous, without warning
9 Hazardous, with warning
8 Very High
7 High
6 Moderate
5 Low
4 Very Low
3 Minor
2 Very Minor
1 None
Occurrence Rank Description
10 >100 Per 1,000
9 50 Per 1,000
8 20 Per 1,000
7 10 Per 1,000
6 5 Per 1,000
5 2 Per 1,000
4 1 Per 1,000
3 0.5 Per 1,000
2 0.1 Per 1,000
1 < 0.01 Per 1,000

Detection Rank Description

10 Absolutely Impossible
9 Very Remote
8 Remote.
7 Very low.
6 Low.
5 Moderate.
4 Moderately High.
3 High.
2 Almost Certain.
1 Certain.
Team Meetings:

Meeting Achievements
Meeting 1 Orientation about FMEA & the infant abduction in hospitals
Meeting 2 Review of the process – Flow chart – Review of the APP.
Meeting 3 Review of the APP and Code yellow report.
Meeting 4 Identification of process failures – causes and effects.
Meeting 5 Identification of process failures – causes and effects.
Meeting 6 Follow up of the recommendations.
Meeting 7 Project closure & celebration.

Tasks Completed by the Team:

- Process flow chart & review.

- Review of Policy Safety & Security System for Newborns
- Review of Code Yellow Report.

Tasks to be completed by the Team:

- Review of Code Yellow drill report conducted.

- Audit the process of baby transfer from L&D to nursery, and from nursery to W1.
- Audit the process of newborn discharge, to make sure that father ID is checked & security is
informed about it.
- Follow up with recommendations.

Identified Failure according to Risk Priority Number from highest to lowest:

Processes Failures RPN

Baby with the mother in W1. Abductor enters the unit. 630
Baby Identification: ID band fell off. 288
Baby discharged home. Abductor tries to abduct the infant. 280
Baby transferred from L&D to Nursery. Baby not in the crib. 270
Baby Identification Wrong entry / registration 180
Baby transferred from L&D to Nursery. Nurse collapse 144
Baby transfer from nursery to W1. Baby can be taken by abductor. 140
Baby discharged home. Wrong baby given to the wrong family. 100
Baby transfer from nursery to W1. Nurse collapse 96
• Please see attached FMEA worksheet for further details.
 Recommendations:

Recommendation
1- To conduct an annual code yellow certification program all Health Care workers in areas caring for Women,
newborns, infants and children.
2- Mother education during antenatal and postpartum care about infant abduction.
3- Code Yellow - Overhead announcement should be heard in the hospital gaits
4- Camera surveillance central control room.
5- Close all the elevators except the two in front of OR after visiting hours.
6- Conduct Arabic Code Yellow training to military police staff.
7- Minimize sitters roaming around. Abductor can act as a visitor to the patient. Therefore, minimizing the entry
of unknown visitors to the patient can minimize the risk.
8- To check the newborn ID band every time the nurse checks the mother vital signs. To make sure the baby ID
is in place, not loose or fell off.
9- To educate all nursing managers and their assistant managers about Human factors engineering. Factors such
as fatigue, stress, overwork, etc. can lead to unintentional errors.
10- Two nurses should accompany the infant during the transfer between units.
11- Ensure that father Identity is being checked prior to baby discharge.
12- Conduct Code yellow drill through involving one of the patients.
13- Audit the baby transfer process between the Units. To make sure that communication is properly done
between the units.
14- Audit the baby discharge process. To make sure that father identity is checked before discharge and security
guards is informed.
15- To audit the drills conducted in the units.
16- To include all OPD & W5 in the code yellow drills, and training.
 1- ID band placed on mom and
baby.
Baby Identification of 2- Registration of baby in the
the baby Quadrumed.
Birth 3- Print face sheet.
4-RFID.

ICN Transfer Nursery W1

1- Visitors.
2- Mother
Education.
3- Double
DC rooms.
NICU DC

DC
1-Identification. 1- Baby Identification by two
2- risk of abduction during nurses.
discharge. 2- risk of abduction during
3- Security Role. transfer.
 PROB

RPN
SEV

DET
Potential
Process Failure Potential Effects Potential
Description Mode of Failure Causes Current Controls Recommended Actions
1- Baby Band fall Misidentification. Loose/ Frequent checking/ Educate nurses to check the baby
Identification: off. damaged/ wet/ Patient Education/ ID band every time they check the
lack of training & vital signs (change the NDPP).
supervision

8 9 4 288

Wrong Baby given to the Multiple births in Double checking. Staff & mother education
entry / wrong family. L&D. - - Mother Invovement.E11
registration Human error
due to stress,
work load.

10 2 9 180
 SEV

PROB

DET

RPN
Potential
Process Potential Effects Potential
Failure Current Controls Recommended Actions
Description of Failure Causes
Mode

Infant abducted - Transfer the mother and the Baby

Baby not in Weak security
Harm to the nurse 10 3 Nursing - Security system. 9 270 together. Two nurses to Transfer
the crib. system.
- harm to the baby. the baby.

2- Baby
transfer from
L&D to
Nursery.

Baby left without

Communication b/w units/
Nurse attention which Nurse health - Proper communication - review
8 2 with proper identification of 9 144
collapse might affect baby's condition. the procedure.
the baby.
health.
 SEV

PROB

DET

RPN
Potential
Potential Effects Potential
Failure Current Controls Recommended Actions
Process of Failure Causes
Mode
Description
3- Baby Baby can be Infant abducted - Unavailable Security system. Enhance the proper practice in
transfer from taken by Harm to the nurse crib. - Nursing Management. baby transfer.
nursery to abductor. - harm to the Lack of
W1. baby. supervision -
Weak security
system.

10 2 7 140

nurse baby left without Nurse health Communication b/w units/ Proper communication. Review the
collapse attention condition. with proper. - procedure. -
Identification of the baby.
-Nursing management (
Human factors )
8 2 6 96
 SEV

PROB

DET

RPN
Potential
Process Potential Effects Potential
Failure Current Controls Recommended Actions
Description of Failure Causes
Mode
4- Baby in Abductor Infant abducted - too many security system - nursing Education to mothers - and staff.
W1. enters Harm to the nurse visitors - too
the unit. - harm to the baby many entry
- mother. points - sitters
roaming -
badge system
monitoring

10 7 9 630

6- Baby Wrong PSYCHOLOGICAL Busy staff - Checking father ID.

discharged baby EFFECT - wrong lack of
home. given to baby identity. checking baby
the ID
wrong
family. 10 2 5 100
abduction - Loss of infant security
- Psychotically
harm to the family
- Hospital
reputation harm. 10 4 7 280