SAT1: Task 2 – RCA and FMEA
FMEA Table
FMEA Table
Steps in the
Improvement
Plan Process *
Failure Mode
Likelihood of
Occurrence
(1–10)
Likelihood of
Detection
(1–10)
Severity
(1–10)
Risk Priority Number
(RPN)
EXAMPLE:
Doctor orders
medication for
pain prior to
invasive
procedure.
Wrong medication selected
3
5
5
75
Doctor orders
IV opioid and
benzodiazepine
to sedate
patient prior to
procedure
Charge nurse to
follow
hospital’s
conscioussedation policy
Nurses to call
for increased
staffing when
needed to
ensure safety
of high-risk
patients
Doctor may order second
dose of same medications
before first has had time
to take full effect
2
5
9
90
Nursing staff may fail to
follow conscious sedation
fully
3
3
8
72
Nursing staff may become
distracted by work
overload and fail to call for
backup staff
5
3
5
75
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SAT1: Task 2 – RCA and FMEA
Nursing staff to
implement
emergency
measures for
dropping O2
sats in a timely
manner
Nursing staff may overlook
critical O2 sats, fail to
implement emergency
measures
FMEA Table
2
4
9
72
Total RPN (sum of all
RPN’s): 309
*do not include more than four steps in the improvement plan process
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