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 PAGE 1 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 PAGE 2