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Once the failure mode is determined, the team will look at the three categories of likelihood, occurrence, and detection. They will also exam the severity of the occurrence if the process was to fail. Each of these categories will be assigned a score between 1 and 10. A score of 1 would have the least likelihood of occurrence, or detection, and minimal severity. A score of 10 would have the greatest chance of occurrence, or detection and a more severe reaction. These scores would then be used to assign a Risk Priority Number(RPN). The higher the RPN number, the higher the priority for change. In the scenario given the cause was an inability to achieve the desired level of sedation. The detection would depend on the severity of the outcome. …show more content…
The IHI offers an interactive tool that allows the creation of a FEMA based on the original process and a FEMA based on the new process. As means of measurement, For the sedition patient, a check list could be established. Charting the time monitors were placed and removed from the patient. Listing the vital signs, levels of consciousness, sensation of nausea or vomiting in short intervals of time. The check list should include a key as to what criteria is need for discharge. As this can be a life or death situation a 100% compliance would be the goal. Someone either from the interdisciplinary team, or some assigned by the team should review every check list ensuring protocol was followed. There would be staff training in the new process. The testing phase should continue over a 6-month time. Giving the opportunity to track progress, assessing if the changes in process are leading to the desired outcomes. If found effective, during the 6-month testing period, the process would then be continued throughout the entire hospital. (Institute for Healthcare Improvement: Failure modes and Effects Analysis Tool report,

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