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Quality Improvement Tools
Jennifer Andrews
Southern New Hampshire University
NUR 409: Strategies for Quality Improvement
Doctor Brittney Mueller
September 14, 2025
, 2
Quality Improvement Tools
FMEA
Scenario B
During a recent hospital merger, the birthing services of two hospitals were combined and
located at one hospital. While the risk of infant abduction is statistically low, the newly formed
hospital wants to ensure that the combined organizations have the safest environment possible
for caring for newborns and limit the risk of infant abduction.
QI Tool: FMEA
Unique Characteristics:
FMEA is an initiative-taking risk assessment tool used to identify, prioritize, and mitigate
potential failures before they occur. It is systematic and team-based, focused on improving
processes by evaluating the severity, occurrence, and detection of potential failures.
Situations for Application:
FMEA is ideal when implementing new systems (such as post-merger processes) or high-
risk procedures, or when safety is a primary concern, such as preventing infant abduction.
Steps in FMEA:
Select a process (newborn discharge protocols).
Map out the process step-by-step.
Identify potential failure modes at each step (failure to verify the authorized person picking up
the baby).
, 3
Assign scores for Severity, Occurrence, and Detection.
Calculate Risk Priority Number (RPN) = Severity × Occurrence × Detection.
Prioritize failure modes based on RPN.
Develop and implement action plans to reduce risk.
Reassess the process after changes are made.
Purpose: A rationalization for the appropriateness of the QI tool to your chosen scenario
The Failure Mode and Effects Analysis (FMEA) tool is specifically designed to
proactively identify and mitigate potential failures in processes before they result in harm. In the
context of Scenario B, where two hospital birthing units have merged, the risk of infant
abduction, although statistically rare, presents a high-impact, high-consequence event that must
be prevented at all costs.
Purpose of FMEA in This Scenario
The purpose of using FMEA in this scenario is to:
Systematically evaluate the new, merged birthing unit processes for any potential vulnerabilities
that could lead to an infant abduction.
Identify failure modes (unauthorized individuals accessing the nursery, malfunctioning ID tag
systems).
Prioritize risks based on severity, likelihood of occurrence, and ability to detect the failure.
Implement changes to reduce or eliminate the most critical risks before any adverse event occurs.
Rationale for Appropriateness
Quality Improvement Tools
Jennifer Andrews
Southern New Hampshire University
NUR 409: Strategies for Quality Improvement
Doctor Brittney Mueller
September 14, 2025
, 2
Quality Improvement Tools
FMEA
Scenario B
During a recent hospital merger, the birthing services of two hospitals were combined and
located at one hospital. While the risk of infant abduction is statistically low, the newly formed
hospital wants to ensure that the combined organizations have the safest environment possible
for caring for newborns and limit the risk of infant abduction.
QI Tool: FMEA
Unique Characteristics:
FMEA is an initiative-taking risk assessment tool used to identify, prioritize, and mitigate
potential failures before they occur. It is systematic and team-based, focused on improving
processes by evaluating the severity, occurrence, and detection of potential failures.
Situations for Application:
FMEA is ideal when implementing new systems (such as post-merger processes) or high-
risk procedures, or when safety is a primary concern, such as preventing infant abduction.
Steps in FMEA:
Select a process (newborn discharge protocols).
Map out the process step-by-step.
Identify potential failure modes at each step (failure to verify the authorized person picking up
the baby).
, 3
Assign scores for Severity, Occurrence, and Detection.
Calculate Risk Priority Number (RPN) = Severity × Occurrence × Detection.
Prioritize failure modes based on RPN.
Develop and implement action plans to reduce risk.
Reassess the process after changes are made.
Purpose: A rationalization for the appropriateness of the QI tool to your chosen scenario
The Failure Mode and Effects Analysis (FMEA) tool is specifically designed to
proactively identify and mitigate potential failures in processes before they result in harm. In the
context of Scenario B, where two hospital birthing units have merged, the risk of infant
abduction, although statistically rare, presents a high-impact, high-consequence event that must
be prevented at all costs.
Purpose of FMEA in This Scenario
The purpose of using FMEA in this scenario is to:
Systematically evaluate the new, merged birthing unit processes for any potential vulnerabilities
that could lead to an infant abduction.
Identify failure modes (unauthorized individuals accessing the nursery, malfunctioning ID tag
systems).
Prioritize risks based on severity, likelihood of occurrence, and ability to detect the failure.
Implement changes to reduce or eliminate the most critical risks before any adverse event occurs.
Rationale for Appropriateness
