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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  
  1. Abbreviations: FSP frequency of occurrence (F), severity of effects (S), probability of detection (P), RPN risk priority number