Table 2 Scoring the failure modes by FSP ranking scales
From: Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards
Failure mode | Frequency of occurrence | Severity of effects | Probability of detection | RPN | Improvement plan |
|---|---|---|---|---|---|
Inflexibility of the medical staff to adopt new practices | 10 | 4 | 3 | 120 | |
Medical staff fixation on familiar dosage regimen | 9 | 4 | 1 | 36 | |
Availability of various new and unfamiliar solutions | 10 | 5 | 3 | 150 | |
KCL solution choice options are limited to only 3 concentrations | 9 | 5 | 9 | 405 | In emergency situations, when high doses of KCL are needed, the pharmacy will supply solutions containing KCL according to the doctor’s prescription (mEq/100 ml (custom-made medication) |
Availability of only 2 types of solution mediums | 10 | 5 | 9 | 450 | In emergency situations, when high doses of KCL are needed, the pharmacy will supply solutions containing KCL according to the doctor’s prescription (mEq/100 ml) |
Lack of pre-prepared KCL solutions in saline 0.45 % | 2 | 5 | 9 | 90 | |
The new solution may be contraindicated in certain medical conditions | 10 | 6 | 10 | 600 | In emergency situations, when high doses of KCL are needed, the pharmacy will supply solutions containing KCL according to the doctor’s prescription (mEq/100 ml) (custom-made medication) |
The solutions are unsuitable for treating acute severe hypokalemia | 9 | 4 | 9 | 324 | In cases of acute severe hypokalemia, the pharmacy will supply concentrated KCL solutions according to the doctor’s prescription (mEq/100 ml) |
A broad variety of solutions in the storage area | 4 | 5 | 9 | 324 | The pharmacy will distribute precise storage orders |
KCL solutions must be stored separately from non KCL solutions | 9 | 8 | 2 | 144 | |
Lack of special handling instructions | 7 | 5 | 2 | 70 | |
Lack of new policy for using the new solutions | 10 | 4 | 2 | 80 |