Table 4 Prioritization of the highest RPNs, with Corresponding Proposed Actions to be implemented to avoid the Occurrence of the Individual Failure Modes
From: Preventing blood transfusion failures: FMEA, an effective assessment method
Phase | before implementation of precautions (RPN score) | action | Major Recommendation | after implementation of precautions (RPN score) |
|---|---|---|---|---|
Patient misidentification | 80 | Eliminated | Using identification devices e.g. Bracelets with an alphanumeric code, Machine-readable bracelets with barcodes | 25 |
Missampling | 75 | Controlled | Training staff, Allocate phlebotomist personnel | 20 |
Mislabeling | 100 | Eliminated | Training staff, Reject potentially mislabeled or misidentified specimens by blood department Automated systems for patient identification and sample labeling | 30 |
Incorrect implementation of order for transfusing blood component | 100 | Eliminated | Formulated Protocol about Appropriateness and safety of blood transfusion and Training on the signs and symptoms of transfusion reactions and about how to initiate early intervention, and submitting specimens and materials | 30 |