The sixth step involves multiplying the three numbers

The sixth step involves multiplying the three numbers from step five to determine a Risk Priority
Number (RPN) for each of the potential failures listed (IHI, 2018). In the final step, the team
will identify the most important failure modes to address by listing them in order from highest
RPN to lowest (IHI, 2018). The ones with the highest RPN’s should be addressed first (IHI,
2018).
FMEA Table
Please see the additional attached document.
Intervention Testing
The improvement plan for this rural ED can be tested using the PDSA cycle. The four
steps involved in this cycle are plan, do, study, and act. The proposed interventions can be tested
by formulating a plan for testing the intervention, doing the planned test and documenting data
and unexpected observations, studying the results by comparing them with predicted outcomes
and summarizing what was learned, then taking action by modifying the change to incorporate
what was learned and getting ready to repeat the cycle again (Provost, Lloyd, & Murray, 2018).
To test the first intervention, the plan would be to collect data regarding medication
related adverse events. The number of documented adverse events associated with unsafe
medication administration from the quarter prior to implementation would be compared to those
during the quarter following implementation. The predicted result would be a decrease in unsafe
medication-related events after the implementation of the medication safety alerts.

TASK 2 12
The second intervention could be tested by calculating the percentage of moderate
sedation cases that were properly monitored and documented during the quarter prior to
implementation, then comparing it to the percentage of properly monitored and documented
moderate sedation cases during the quarter after implementation. The expectation would be that
the percentage of cases that were properly monitored and documented would increase. The third
intervention could also be tested using this data, however, only one intervention could be
measured at a time to ensure valid results.
The fourth intervention could be tested by creating a moderate sedation competency
evaluation and administering it to all employees in the ED who are eligible to administer
moderate sedation prior to implementation of the intervention. Those employees would receive
training using the modified training module and would be given the moderate sedation
competency evaluation again. The expected result would be an increase in the number of
employees who successfully complete the moderate sedation competency evaluation.
The final intervention can be tested by determining the average daily staffing ratio for the
quarter prior to implementation and comparing it to the average daily staffing ratio for the
quarter following the implementation of the change. The prediction would be that the average
daily staffing ratio would be closer to, or matching, the established safe staffing ratio.
These tests would be carried out, one at a time, as the second step in the PDSA cycle.