Table 3 Evaluation of Risk Priority Numbers (RPNs) including the Severity Score, the Probability of Occurrence Score, and the Probability of Detection Score and related corrective action for highest RPN – Steps1–3
From: Preventing blood transfusion failures: FMEA, an effective assessment method
Step | Failure mode | Possible cause | (O) | (D) | (S) | RPN | Action |
|---|---|---|---|---|---|---|---|
Ordering blood request | - Inappropriate ordering (kind and amount) of blood/blood component* - Ordering transfusion of blood products for a patient who does not need blood transfusion or vice versa - Overuse or underuse of blood products - Physician use of fresh frozen plasma instead of Cryoprecipitate for controlling blood dyscrasia | - Inappropriate assessment of patient’s clinical need for blood, and when required. - not being able to check that the ordered product is the most suitable with regard to diagnosis | 3 | 2 | 1 | 6 | - |
- Blood plasma abuse | Blood plasma still used in volume expansion, as nutritional supplement and to improve immunoglobulin levels | 1 | 2 | 1 | 2 | ||
Incorrectly recorded patient characteristics | - Look alike patient names | 1 | 4 | 4 | 16 | ||
Incomplete filling of the request form | - New patient orders into a record from a prior encounter | 5 | 3 | 3 | 45 | ||
- incorrect or incomplete entry of the patient’s data | - Environment factors | 1 | 5 | 4 | 20 | ||
- Incorrect entry of results in the database of the Laboratory Information System. | - Request form filled out incorrectly/incompletely | 1 | 5 | 4 | 20 | ||
- Inappropriate assessment of patient’s clinical need for blood, and when required. | Staff negativity Heavy workload Low level of literacy patients | 3 | 2 | 1 | 6 | ||
Patient identification | -Incorrect patient identification | - Patient’s with same name - Time constraints | 2 | 5 | 5 | 50 | - Using identification devices e.g. Bracelets with an alphanumeric code, Machine-readable bracelets with barcodes or radiofrequency identifier devices (RFID), Machine-readable anthropometric data. |
-Not Checking ID Bracelet | - Unaware - Non adherence to guideline, assumption that -admission process and/or assessment by doctor has confirmed identity | 4 | 5 | 4 | 80 | ||
Blood taking from patient (sampling) | -Taking blood from the wrong patient | - Mismatched information on specimen and requisition - Not Check ID wristbands of patient - Non adherence to guideline, workload (multiple patients to attend to) or incorrect patient documents taken to bedside - Unlabeled tubes taken from bedside and cluttered workspace which multiple staff use causes confusion - Technical error in sampling by nursing staff | 3 | 5 | 5 | 75 | - Training and frequent education should be provided to phlebotomy staff responsible for drawing blood bank specimens. - Hand labeling of specimens at the patient’s bedside should be mandatory - Clinical staff given training courses on blood transfusion - Allocate phlebotomist personnel - Sign in phlebotomist’s name on sample tube |
Steps 4 and 5 | |||||||
attaching labels on tubes, and Sending the samples and request form | - Labels attached to tube at nursing station | - Non-use from scanners and label printers for patient ID and specimen labeling | 4 | 5 | 5 | 100 | - Reject potentially mislabeled or misidentified specimens - Safe environment - Automated systems for patient identification and sample labeling - Strict adherence to standard guidelines and recommendations for specimen collection - Service staff given training courses on transport blood bag and sample of patient |
- Labeling tubes some patients simultaneously | - inadequate equipment - lack of policy procedure | 4 | 5 | 5 | 100 | ||
- Pre written labels at work station | - Lack of supervision and continuing education | 4 | 5 | 5 | 100 | ||
- Mismatch between the labels on the tubes and the request form | - Designing of Process of Blood Collection - Non-compliance with the cold chain | 4 | 4 | 3 | 80 | ||
analysis of blood samples | - Incorrect blood group | - Non-use of Guidelines | 1 | 5 | 5 | 25 | Â |
- Incorrect typing, technical error | - Knowledge deficit | 2 | 5 | 2 | 20 | ||
- Incorrect typing, clerical error | - Lack of supervision and continues monitoring | 2 | 5 | 2 | 20 | ||
Inaccurate cross-matching | - Inexpert staff | 1 | 5 | 5 | 25 | ||
- Incorrect specimen used for testing | - No calibration equipment | 2 | 4 | 2 | 16 | ||
Non Checking of sample and request Form | - User error | 1 | 1 | 5 | 5 | ||
Not Verifying blood type with historical type of patient | - Misinterpretation | 1 | 5 | 1 | 5 | ||
Steps 6 and 7 | |||||||
Preparing and delivering blood bag | - Errors in Record the identification patient | - Inexpert staff - Poorly visible labels and request form - Unsafe technique when preparing blood - Knowledge deficit | 1 | 5 | 3 | 15 | Â |
- Wrong product - Wrong blood bag being sent from blood bank ward | - Inefficient blood delivery system - Inadequate staff and equipment | 1 | 5 | 3 | 15 | Â | |
- Delivered blood bag to the wrong unit | - Untimely communication - Human factors - Heavy workload at the blood bank - A large number of blood samples have to be delivered to different departments at the same time - Waiting for an elevator, limited staff for delivering blood | 1 | 5 | 5 | 25 | ||
Transfusing blood components | No Double-checking at bedside with patient’s ID band by two nurses and sign their names | - Human factors - Knowledge deficit - Heavy workload in ward | 4 | 2 | 4 | 32 | - Training on the signs and symptoms of transfusion reactions - Training about how to initiate early intervention, and submitting specimens and materials - Necessary for completing a transfusion workup - Protocol should mandate close monitoring of the patient during the first 10 to 20 min of transfusion. - Development accountability and special attention to problems of transfusion and reporting errors |
Not verifying the type, quality, amount, and kind of the blood taken from the blood bank ward | Knowledge deficit - Lack of standard procedure | 3 | 3 | 4 | 36 | ||
- Failure to monitoring for signs in the first 15Â min | - Lack of standard procedure - Knowledge deficit | 5 | 3 | 5 | 75 | ||
- preparation time before infusion of more than 30 min and non-checked Vital signs every 30 min until the transfusion is complete | - Patient not informed to alert practitioners to treat symptoms - Non Complete records - The transfusion doesn’t complete within 4 to 6 h | 5 | 3 | 5 | 75 | ||
- Treat condition/not educated patient | - The final patient identification check at the bedside not performed by nurses - Inappropriate transfusion time | 5 | 5 | 4 | 100 | ||
Failure to comply with the standard conditions in the maintenance of blood in ward | Â | 3 | 2 | 4 | 24 | ||
- Blood transfusion reaction occurring during the transfusion process and non suitable control by nurse | Â | 1 | 3 | 3 | 9 | ||