Table 2 Risk analysis and RPN of the hospital radiology department
Stage | Processes | Element | Potential failure modes | Severity (S) | Occurrence (O) | Detection (D) | RPN | Rank |
|---|---|---|---|---|---|---|---|---|
Before starting CT (A) | CT request form (A1) | Human | The CT request form does not meet the relevant norm, such as incomplete signs and symptoms (A11) | 5.00 | 4.00 | 3.50 | 70 | 15 |
Patient has obtained a CT request form but does not know the procedure (A12) | 5.50 | 5.00 | 4.00 | 110 | 4 | |||
Patient cannot find the CT room (A13) | 5.00 | 5.00 | 4.50 | 112.5 | 3 | |||
Machine | Examination for multiple body parts billed on the same CT request form (A14) | 3.00 | 5.00 | 2.00 | 30 | 31 | ||
Regulations | Excessive CT for COVID-19 Patients (A15) | 3.50 | 3.00 | 4.50 | 47.25 | 21 | ||
Priority of CT for emergency patients is not strictly implemented (conflicts with CT for outpatients) (A16) | 5.00 | 4.00 | 4.00 | 80 | 12 | |||
Patient identification (A2) | Human | Before CT, technician fails to input patient information correctly (A21) | 9.00 | 2.00 | 2.00 | 36 | 25 | |
Before CT, technician fails to check the patient identification information normatively (A22) | 7.50 | 2.00 | 2.00 | 30 | 31 | |||
Before CT, technician fails to check the CT examination site correctly (A23) | 8.50 | 2.00 | 2.00 | 34 | 26 | |||
Before CT, technician fails to check patient’s identity and wristband information correctly (A24) | 8.00 | 2.00 | 2.00 | 32 | 27 | |||
Machine | Barcode gun malfunctions during information verification (A25) | 3.00 | 2.00 | 2.00 | 12 | 39 | ||
Technician entering the operating room (A3) | Human | Technician fails to wear N95 mask normatively (A31) | 8.00 | 1.00 | 3.00 | 24 | 36 | |
Technician fails to wear isolation gowns normatively (A32) | 7.00 | 2.00 | 2.00 | 28 | 35 | |||
Technician lacks hand disinfection knowledge or fails to finish hand disinfection normatively (A33) | 8.00 | 2.00 | 4.00 | 64 | 17 | |||
object | Insufficient management of the reserve of infection protection materials, such as N95 masks, isolation gowns, and hand disinfectants (A34) | 8.00 | 2.00 | 2.00 | 32 | 27 | ||
Environment | The buffer zone between the CT operation room and CT room (changing isolation gowns) does not meet the requirements of prevention and control of COVID-19, including national regulations or hospital standards (A35) | 9.00 | 1.00 | 2.00 | 18 | 38 | ||
During CT (B) | Before the CT patient’s boarding (B1) | Human | Patient does not remove metal objects (images may have artifacts) (B11) | 6.00 | 3.00 | 2.50 | 45 | 22 |
object | Life-saving medical equipment may affect CT scan, such as a large transfer bed (B12) | 5.00 | 2.00 | 2.00 | 20 | 37 | ||
During the scan of CT patient (B2) | Human | Poor respiratory coordination of patient(B21) | 5.00 | 5.00 | 3.50 | 87.5 | 9 | |
Incorrect patient position (B22) | 5.00 | 2.00 | 3.00 | 30 | 31 | |||
Patient gets into bed difficulty (B23) | 4.00 | 4.00 | 3.00 | 48 | 20 | |||
Patient is too unwell to continue with the CT scan (B24) | 6.50 | 3.00 | 5.00 | 97.5 | 5 | |||
Nurse does not select the vein well, resulting in extravasation of the peripheral vein for enhanced CT (B25) | 8.00 | 3.00 | 5.00 | 120 | 2 | |||
The process of CT patient getting off the machine (B3) | Human | Patient gets off the machine too quickly or has difficulty (B31) | 5.00 | 2.50 | 2.50 | 31.25 | 30 | |
object | CT machine is too high or not exiting, resulting in machine failure (B32) | 7.50 | 2.00 | 2.00 | 30 | 31 | ||
Common potential failure modes(B4) | Human | Technician fails to finish hand hygiene normatively (B41) | 6.00 | 3.00 | 4.00 | 72 | 14 | |
Technician fails to communicate with the patient effectively (B42) | 5.00 | 3.00 | 4.00 | 60 | 19 | |||
Patient fails to wear the mask normatively (B43) | 5.50 | 5.00 | 3.00 | 82.5 | 11 | |||
After CT (C) | The process of patient getting off CT room (C1) | Human | Patient forgets belongings (C11) | 3.00 | 3.00 | 4.50 | 40.5 | 23 |
Patient enquires about the time of output of the CT report (C12) | 2.00 | 6.50 | 3.00 | 39 | 24 | |||
CT room and objects disposal (C2) | Human | Auxiliary staff (or technician) does not have a good grasp of the sterilization and disinfection standards (C21) | 6.00 | 3.00 | 5.00 | 90 | 6 | |
Auxiliary staff (or technician) does not sterilize the CT machine thoroughly (C22) | 6.00 | 3.00 | 5.00 | 90 | 6 | |||
Auxiliary personnel (or technician) does not sterilize the air in the CT room thoroughly (C23) | 6.50 | 3.00 | 4.00 | 78 | 13 | |||
Auxiliary staff (or technician) does not sterilize the X-ray protective clothing thoroughly, such as lead cloth, lead gown, lead bib, etc. (C24) | 7.00 | 3.00 | 4.00 | 84 | 10 | |||
Regulations | The COVID-19 prevention and control system of the CT room does not meet relevant standards (including environment, machines, etc.), including national regulations or hospital standards (C25). | 8.00 | 2.00 | 2.00 | 32 | 27 | ||
Medical waste (garbage) disposal (C3) | Human | Cleaning personnel does not handle medical waste normatively (C31) | 7.50 | 3.00 | 3.00 | 67.5 | 16 | |
Cleaning personnel does not wear masks normatively (C32) | 8.00 | 4.00 | 4.50 | 144 | 1 | |||
Cleaning personnel lacks of knowledge of COVID-19 prevention and control (C33) | 7.50 | 4.00 | 3.00 | 90 | 6 | |||
Regulations | The infection prevention and control system of medical waste in CT rooms is imperfect, which should meet the national regulations or hospital standards (C34). | 8.00 | 2.00 | 4.00 | 64 | 17 |