contoh fmea wrong blood in tube

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9/14/2015 Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=18663&ScenarioId=20717&Type=1 1/1 Failure Modes and Effects Analysis (FMEA) Tool Copy of Wrong blood in tube United States HospitalCommunity Aim: To prevent drawing blood on the wrong patient ultimately reduce wrong blood in tube. Process Data Date: 11/10/2014 Step Description 1 MD placed order for blood draw Step Description 2 The RN should be triggered to draw blood when order is placed Step Description 3 RN makes not of time and day lab is to be drawn Step Description 4 RN to collect supplies to draw blood Step Description 5 RN verifies two patient indicators before drawing blood Step Description 6 RN draws blood Step Description 7 RN labels blood with time, date and initials Step Description 8 Second RN verifies label and blood drawn Step Description 9 RN sends blood to lab Step Description 10 RN waits for results to be posted in EHR Calculated Totals Total Risk Priority Number for the process Occ: Likelihood of Occurrence (110) Det: Likelihood of Detection (110) NOTE: 1 = Very likely it WILL be detected 10 = Very likely it WILL NOT be detected Sev: Severity (110) RPN: Risk Priority Number (Occ × Det × Sev) Annotation None

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Page 1: contoh FMEA Wrong Blood in Tube

9/14/2015 Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=18663&ScenarioId=20717&Type=1 1/1

Failure Modes and Effects Analysis (FMEA) Tool

Copy of Wrong blood in tube

United StatesHospital­Community 

Aim: To prevent drawing blood on the wrong patient ultimately reduce wrong blood in tube. 

Process Data 

Date: 11/10/2014 

Step Description1 MD placed order for blood draw

Step Description2 The RN should be triggered to draw blood when order is placed

Step Description3 RN makes not of time and day lab is to be drawn

Step Description4 RN to collect supplies to draw blood

Step Description5 RN verifies two patient indicators before drawing blood

Step Description6 RN draws blood

Step Description7 RN labels blood with time, date and initials

Step Description8 Second RN verifies label and blood drawn

Step Description9 RN sends blood to lab

Step Description10 RN waits for results to be posted in EHR

Calculated Totals

Total Risk Priority Number for the process ­­

Occ:   Likelihood of Occurrence (1­10)Det:   Likelihood of Detection (1­10)  NOTE:  1 = Very likely it WILL be detected

  10 = Very likely it WILL NOT be detectedSev:  Severity (1­10)RPN:  Risk Priority Number (Occ × Det × Sev)

AnnotationNone