Ratings | |||||
---|---|---|---|---|---|
Failure number | Failure | Sev | Prob | Det | RPN |
1 | No mechanism of direct communication between homecare, hospitalist, PCPs about high-risk, complex patients | 9 | 9 | 7 | 567 |
2 | Content of communication between homecare, hospitalists, PCPs is not accurate/complete. | 7 | 8 | 1 | 56 |
3 | Inpatient and outpatient care do not work together as a team | 9 | 9 | 10 | 810 |
4 | No standard agreement on risk identification / the underestimation of risk | 9 | 8 | 9 | 648 |
5 | Lack of common understanding of who does what when | 7 | 8 | 8 | 448 |
6 | Medication reconciliation – lack of understanding about what it is, when it should happen | 9 | 8 | 9 | 648 |
7 | Learning curve for the patient in the hospital | 9 | 7 | 10 | 630 |
8 | Lack of assessment of patient / caregiver skills / abilities | 8 | 8 | 6 | 384 |
9 | Lack of patient engagement / underappreciation of patient needs | 7 | 8 | 4 | 224 |
10 | Patient doesn’t know who to call (PCP or homecare) under varying circumstances | 6 | 4 | 10 | 240 |
11 | Patient preferences different to caregiver perception | 8 | 10 | 4 | 320 |
12 | Staff resources overwhelmed | 9 | 7 | 6 | 378 |
13 | Patient at risk between their arrival home and homecare nurse arrival | 8 | 7 | 6 | 336 |
PCP = primary care physician