Table 3.
Summary of Failure Mode and Effect Analysis- Critical Results (RPN ≥200)
| Process | Failure Modes | Causes | Effects | RPN1 | RPN2 | % |
|---|---|---|---|---|---|---|
| Ordering Phase | Missed test | Lack of adequate nursing follow up (organization and management, and Work environment factor) | Delay in treatment plan |
200 | 90 | 55% |
| Phyiscans or nurse incharge did not inform the assigned nurse (Team factor) | 240 | 90 | 63% | |||
| No systematic process to follow-up the pending lab test (organization and management factor) | 245 | 110 | 55% | |||
| Incharge- high workload (Work environment and Individual staff member factors) | 350 | 210 | 60% | |||
| Informing wrong inforamtion | Phyiscans or nurse incharge informs the assigned nurse wrong information (Team factor) | Wrong lab results lead to wrong treatment | 420 | 80 | 81% | |
| Incharge- high workload (Work environment factor) | 350 | 210 | 60% | |||
| Wrong patient | Improper patient identification (Work environment and Individual staff member factor) | 288 | 90 | 69% | ||
| High workload (Work environment factor) | 350 | 210 | 60% | |||
| Wrong test | Improper patient identification (Work environment and individual factor) | 200 | 90 | 55% | ||
| High workload (Work environment and Individual staff member factor) | 350 | 210 | 60% | |||
| Prepartion phase | Wrong patient in tube | Improper patient identification (organization and management factor) | Wrong lab results lead to wrong treatment | 240 | 110 | 54% |
| Printing labels for all patients once, without cutting labels for each patient (organization and management factor) | 441 | 130 | 71% | |||
| Wrong or extra label printing (organization and management factor) | 288 | 90 | 69% | |||
| Improper chart review and verification (Work environment and Individual staff member factors) | 225 | 110 | 51% | |||
| Unclear information on the stickers due to small size of written information (organization and management factor) | 225 | 90 | 60% | |||
| A lot of information in the stickers (organization and management factor) | 245 | 80 | 67% | |||
| Unnecessary motion/rework and increase the risk for interruptions during blood sampling process (organization and management factor) | 245 | 120 | 51% | |||
| There is no visualized material to instruct the nurses about preparing blood samples ( organization and management, and Individual staff member factors) | 225 | 90 | 60% | |||
| Wrong tube | Putting lable in wrong tube (Individual staff member factors) | Wrong lab results lead to wrong treatment | 441 | 170 | 61% | |
| Unnecessary motion/rework and increase the risk for interruptions during blood sampling process (organization and management factor) | 245 | 120 | 51% | |||
| Wrong test | Selecting wrong test in the system (Work environment and individual staff member factors) | Wrong lab results lead to wrong treatment | 225 | 150 | 33% | |
| Unnecessary motion/rework and increase the risk for interruptions during blood sampling process (organization and management factor) | 225 | 120 | 47% | |||
| Sampling Phase | Wrong patient | Improper patient identification before sampling (Work environment and individual staff member factors) | Wrong lab results lead to wrong treatment | 220 | 110 | 50% |
| Starting sampling process for many patient at one time (organization and management factor) | 260 | 90 | 65% |