List 4 steps in your Improvement Plan Process * List 1 Failure Mode per step Likelihood of Occurrence (110) Likelihood of Detection (110) Severity (110) Risk Priority Number (RPN) Example: On-call staff must clock in within 30 minutes of being notified. On-call staff forget to clock in when arriving to the unit. 4 5 2 40

1. Sedation is ordered by physician in computer Order is placed incorrectly in computer 3 5 8 120
2. RN notifies Charge Nurse and indicates need for checklist activation

RN acknowledges orders and is unable to find Charge Nurse/ too busy with other patients 7 8 7 392

1. Charge Nurse and RN review orders including medications needed

Medications are not reviewed, and wrong medications are ordered 5 2 7 70

1. Checklist is implemented and available at...