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Wrong Blood in Tube
Wrong Blood in Tube
InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport
FailureModesandEffectsAnalysis(FMEA)Tool
CopyofWrongbloodintube
UnitedStates
HospitalCommunity
Aim:Topreventdrawingbloodonthewrongpatientultimatelyreducewrongbloodintube.
ProcessData
Date:11/10/2014
Step
Description
MDplacedorderforblooddraw
Step
Description
TheRNshouldbetriggeredtodrawbloodwhenorderisplaced
Step
Description
RNmakesnotoftimeanddaylabistobedrawn
Step
Description
RNtocollectsuppliestodrawblood
Step
Description
RNverifiestwopatientindicatorsbeforedrawingblood
Step
Description
RNdrawsblood
Step
Description
RNlabelsbloodwithtime,dateandinitials
Step
Description
SecondRNverifieslabelandblooddrawn
Step
Description
RNsendsbloodtolab
Step
Description
10
RNwaitsforresultstobepostedinEHR
CalculatedTotals
TotalRiskPriorityNumberfortheprocess
Occ: LikelihoodofOccurrence(110)
Det: LikelihoodofDetection(110)
NOTE: 1=VerylikelyitWILLbedetected
10=VerylikelyitWILLNOTbedetected
Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)
Annotation
None
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=18663&ScenarioId=20717&Type=1
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