Steps in the Process Failure Mode Failure Causes Training for ALL staff annually on Conscious Sedation Staff doesn't get timely training. Schedules are to busy for all training Incorporating a bundle order set for all orders Staff doesn't use the order set Takes to much time to complete. Anestheiologist available for sedation Unavailable staff for ED situations Low staffing and uncontrollable ED events 1:1 staffing after procedure is completed. Emergency situation arises and staff is needed. Unplanned emergent situations. Call outs. Ensure all sedation reversal agents at bedside Pharmacy unavailable/nursing staff unavailable. Not enough staff during emergency events
Failure Effects Severity 5 5 7 175 7 9 8 576 3 5 8 120 6 8 9 432 5 8 9 360 Likelihood of Occurrrence Likelihood of Detection Risk Profile Number Not all staff is trained and process isn't followed leading to potential patient harm. Pt doesn't get appropriate VS
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- Fall '17
- sedation., 3 5 8 120 Pt, 5 5 7 175 Pt