DATE

PROCESS:
REASON CHOSEN

CONSEQUENCES
Risk # STEP # PROCESS STEP Potential failure mode Potential effects of failure
(Consequences)

1-5
 Potential ###
Failure Modes and Effects Analysis ###
(Design FMEA) ###
###
###

CONSEQUENCES

DETECTABILITY
DETECTABILITY
LIKELIHOOD

LIKELIHOOD
Potential Recommended actions Responsibility (PIC) Target completion Action taken

RPN

RPN
cause(s)/mechanisms of date
failure

1-5 1-5 1-5 1-5 1-5

0
0
0
0
 CONSEQUENCES CA

CATEGORY SERIOUS (5) MAJOR (4)

Multiple Severe Health Crises/ Injuries Severe Health Crisis and / or injuries.
or death, causally related to the risk Prolonged incapacity or absence
being contemplated, of individual beyond 3 month

Patient :with death unrelated to the
course of their illness and different to
the expected outcome of the patient
management or any of the following:
Patients : with major permanent loss of
function (sensory, motor, physiologic or
psychologic) unrelated to the natural
course of their illness and different to
the expected outcome of the patient
management or any of the following

·          Sentinel event · Disfigurement as a result of the

Patient

incident
·          Procedures involving the wrong · Patient at risk absent against medical
HEALTH IMPACT

patient or body part advice

·          Possible suicide · Threatened or actual physical or
verbal assault of patient or staff
requiring police intervention
·          Retained instruments

·          Infant abduction or discharge to

wrong family

·          Any error resulting in death of the

patient
Death of staff member related to any Permanent injury or resulting loss
work incident or hospitalization of 3 or hospitalization or loss of work time for 2
Staff

more staff or more staff

Death of visitor or hospitalization of 3 or Hospitalization of up to 2 visitors related

Visitor

more visitors to the incident/injury

Indeterminate prolonged suspension of Prolonged suspension of work.

work. Impact not manageable. Non Additional resouurces, budget,
Services

Performance. Other providers appointed management assesstenance requiered,

performance criteria compromised
 1. loss of assets due to damage/fire etc 1. Loss of assets due to damage/fire etc
with replacement value of >US$1million with replacement value of >US$100K-1
million.

2. Loss of assets due to 2. Loss of assets/cash due to

fraud/theft/overpayment >US$100K
Financial
Performance to Budget : More
than 10 % temporay over budget, or a
significant over - run not recorverable
within the financial year, or being
unable to pay staff or finance critical
service
Environmental
fraud/theft/overpayment >US$10K –
100K
Performance to Budget : More
than 5% to 10% temporarily over
budget, or a significant over-run not
recoverable within the financial year

Toxic release with detrimental effect or Toxic release with no detrimental effect
fire requiring evacuation or fire contained fire without evacuation

Non achievement of Organizational Organizational Objectives or outcomes::

Organizational

objectives/ outcome. Significant delays.

Total Performance failure Performance significantly under target

1. Actual receipt of letter of legal action 1. Formal complaint that is considered

brought against the company serious and unresolved with potential
threat of adverse media coverage
Reputation

2. Maximum multiple high level 2. Headline profile. Repeated exposure

exposure. Ministerial censure Direct at fault or unresolved complexties
intervention. impacting public or key groups.
3. Loss of credibility and Public / key 3. Ministerial
stake holder support involvement

Serious and willfull breach. Criminal Deliberate breach, or gross negligence,

negligence or act. Litigation or Significant harm. Formal investigation.
Legal

prosecution with significant penalty. Disciplincary action. Ministerial

Dismissal ministerial censure involvement

SCORE 5 4
ONSEQUENCES CATEGORY TABLE

MODERATE (3) MINOR (2)

Increased level of medical attention Routine Medical attention required.

required. Prolonged diminution or loss Temporary diminution or loss of normal
of normal bodily/ mental health or bodily/ mental health or function. Max 2
function. 2 weeks to 3 months weeks incapacity/ time lost
incapacity time / lost

Patient : with permanent reduction in Patient – requiring increased level of

bodily function (sensory, motor, care including:
physiologic or psychologic) unrelated to
the natural course of their illness and
different to the expected outcome of
the patient management or any of the
following:

·          Increased length of stay as a ·          Review & evaluation

result of the incident
·          Surgical intervention required as ·          Additional investigations
a result of the incident
Near Miss event which could have ·          Referral to another clinician
resulted in serious/major/moderate
consequences for the patient
Near miss event which could have
resulted in minor/minimum
consequences for the patient if the
incident had occurred

Medical expenses/lost time or First aid treatment only with no lost

restricted duties or injury/illness for 1 time or restricted duties
or more staff

Medical expenses incurred or Evaluation or treatment with no

treatment of up to 2 visitors not expenses
requiring hospitalization

Medium temporary suspension of 1. reduced efficiency or disruption to

work. Backlog requires extended work working
of overtime or additional resources to 2. Short term temporary suspension
clear. Manageable impact of work. Blocklog cleared inday.
Nopublic impact
1. loss of assets due to damage/fire etc
with replacement value of >US$50K-
100K
Loss of assets replacement value due
2. Loss of assets/cash due to to damage, fire etc up to US$50K
fraud/theft/overpayment up to US$10K

Performance to Budget : Performance to Budget :

More than 2% up to 5% temporarily More than 1% up to 2% temporary over
over budget budget

Toxic release contained with outside

Toxic release contained without outside
assistance or fire occurrence at
assistance
beginning stage only

Organizational Objectives or outcomes: Organizational Objectives or

Material delays, marginal under outcomes : Incovenient delays
achievement of target performance

1. Formal complaint that is considered 1. informal complaint with minimal

moderate in nature with possible threat of adverse media coverage
adverse media coverage

2. Repeated non headline exposure. 2. Non-headline exposure. Clear fault.

Slow resolution. Ministerial enquiry / Settled quickly by
briefing. departmentalresponse. Negligible
impact.

Negligent breach. Lack of good faith Negligible breach. Klack of good faith
evident. Performance review Initiated. evident. Performance review initiated.
Material harm caused Material harm caused

3 2
 INSIGNIFICANT (1)

First aid or equivalent only

Patient – with no injury or increased

level of care or length of stay

Near miss event which would not have

resulted in an adverse consequences
for the patient if the incident had
occurred

No injury or review required

No treatment required or refused

treatment

1. No loss of service 2.
No material disruption to dependent
work
 No financial loss

Performance to Budget :
up to 1%temporarily over
budget

Nuisance releases

Organizational Objectives or outcomes :

Little impact

1. resolved complaint with no threat of

adverse media coverage

2.No headline exposure. Not at fault.

Settled quickly. No impact

Innocent procedural breach. Evidence

of good faith by degree of care/
diligence. Little impact

1
 Likelihood Score Definition of Occurences
Categories

Rare Unlikely to recur – or may occur in exceptional circumstances (may happen every 5-30
years)
Unlikely Possibly will recur (could occur at some time in 2-5 years)

Possible Possibly will recur – or might occur at some time (may happen every 1-2 years)

Likely Will probably occur in most circumstances (several times per year)

Frequent Is expected to occur again either immediately or within a short period of time (likely to
occur most weeks or months)
SCORE

5
 Detectablelity Score

Immidiately Detectable 1

Easy to Detect 2

possible to Detect 3

Unlikely to Detect 4

Not Detectable Until is too Late 5

Potential Failure Potential Causes of Potential Effects of
Mode Failure Failure
ACTION PLAN

Recommended Action(s) to achieve Implemented by

Action recommendations (how) Whom
Implemented When Implemented Where Resources/Fund