NURS 6223 Week 5 Failure Modes Analysis Example

Course	NURS 6223 Healthcare Quality Assurance and Risk Management in Healthcare Organizations
Week	Week 5
Paper type	Failure modes and effects analysis
Length	About 660 words, 5 pages
Format	APA 7 student paper
School	Walden University
Program	Master of Science in Nursing (MSN)
Updated	October 2026

Free sample paper for NURS 6223 Week 5

Failure Modes and Effects Analysis: Blood Administration on a Medical-Surgical Unit

Student Name

College of Nursing, Walden University

NURS 6223: Healthcare Quality Assurance and Risk Management in Healthcare Organizations

Instructor Name

Month Day, Year

What this page is doingThe analysis asks how each step could fail before any of them has. Every rating is a team estimate and is labeled as one.

Failure Modes and Effects Analysis: Blood Administration on a Medical-Surgical Unit

Team and Process

The team for this composite analysis included a medical-surgical staff nurse, the unit's charge nurse, a transfusion service medical technologist, a phlebotomist, a hospitalist, a patient transport aide and a patient safety specialist as facilitator. The method follows the healthcare failure mode and effects analysis approach developed by the VA National Center for Patient Safety, which maps a high-risk process, identifies how each step could fail and prioritizes the failure modes for redesign (DeRosier et al., 2002).

The team mapped blood administration in eight steps: (1) order, (2) consent, (3) specimen collection and labeling, (4) type and crossmatch, (5) release from the blood bank, (6) transport, (7) two-person bedside verification, and (8) administration with monitoring.

Worksheet

Severity (S), occurrence (O) and detection (D) are each rated from 1 to 10, with 10 the worst, and multiplied into a risk priority number (RPN). All ratings are team estimates.

Table 1

Failure Modes, Effects, Causes and Ratings

Step	Failure mode	Effect on patient	Likely cause	S	O	D	RPN
1 Order	Wrong product or missing special requirement (irradiated, washed)	Transfusion-associated complication	Order set lacks prompts for special needs	7	3	5	105
2 Consent	Consent not obtained or not documented	Transfusion without informed agreement	Consent treated as a formality at night	4	3	3	36
3 Specimen	Specimen labeled away from the bedside	Wrong blood in tube; incompatible unit issued	Batching of tubes; labels printed at the station	10	4	8	320
4 Crossmatch	Testing on wrong specimen	Incompatible unit issued	Specimen mix-up in the laboratory	10	2	5	100
5 Release	Wrong unit released	Incompatible unit sent to unit	Look-alike units; release under time pressure	10	2	4	80
6 Transport	Unit delayed or mishandled	Product wasted or delayed	Transport aide unavailable	4	4	3	48
7 Verification	Two nurses verify by reading the same screen rather than checking the patient's band	Wrong patient receives the unit	Verification done at the station; interruption	10	4	8	320
8 Administration	Inadequate monitoring in first 15 minutes	Delayed recognition of reaction	Nurse leaves bedside for other duties	8	4	4	128

What this page is doingEvery rating carries its label as an estimate. The value of the worksheet is the ranking it produces, not the precision of any single number.

Ranking and the Two Highest Risks

Ranked by RPN, steps 3 and 7 lead at 320, followed by monitoring (128), ordering (105) and crossmatch (100). The two leaders share a structure: both are identification checks that can be performed away from the patient, and when they are, the check confirms that paperwork agrees with paperwork rather than that the patient is the right one.

A specimen labeled at the station after collection is the classic route to a wrong-blood-in-tube error, which silently sends the wrong patient's blood group through every later check. In an international study of more than 690,000 samples, the median hospital had a miscollected-sample rate of about 1 in 2,000 outside countries with national patient identification systems (Dzik et al., 2003). Verification done by two nurses reading the same screen at the station fails in the same way. In ten years of mandatory reports in New York State, about half of transfusion errors occurred outside the blood bank, most often administration to the wrong recipient, and the most common compounding error was failure to detect at the bedside that the wrong unit had been issued (Linden et al., 2000).

Redesigns

Table 2

Redesign for Each High-Ranked Failure Mode

Failure mode	Redesign	Accountable role	Rescore plan
Specimen labeled away from bedside	Labels printed only at the bedside by scanning the patient's wristband; no pre-printed labels	Director of laboratory services with nursing informatics	Rescore after three months of use; track rejected and mislabeled specimens
Verification by screen reading	Bedside barcode scan of patient band and unit required before the infusion pump can start	Director of medical-surgical nursing	Rescore after three months; audit ten transfusions a month
Inadequate early monitoring	Nurse remains at bedside for first 15 minutes; charge nurse covers other patients	Unit nurse manager	Rescore after three months; audit documentation of first vital signs

References

DeRosier, J., Stalhandske, E., Bagian, J. P., & Nudell, T. (2002). Using health care failure mode and effect analysis: The VA National Center for Patient Safety's prospective risk analysis system. The Joint Commission Journal on Quality Improvement, 28(5), 248-267. https://doi.org/10.1016/S1070-3241(02)28025-6

Dzik, W. H., Murphy, M. F., Andreu, G., Heddle, N., Hogman, C., Kekomaki, R., Murphy, S., Shimizu, M., Smit-Sibinga, C. T., & Biomedical Excellence for Safer Transfusion Working Party of the International Society for Blood Transfusion. (2003). An international study of the performance of sample collection from patients. Vox Sanguinis, 85(1), 40-47. https://doi.org/10.1046/j.1423-0410.2003.00313.x

Linden, J. V., Wagner, K., Voytovich, A. E., & Sheehan, J. (2000). Transfusion errors in New York State: An analysis of 10 years' experience. Transfusion, 40(10), 1207-1213. https://doi.org/10.1046/j.1537-2995.2000.40101207.x

What the NURS 6223 Week 5 instructions ask for

Week 5 of NURS 6223 typically asks for a failure modes and effects analysis of a clinical process. You name the team, map the process, list failure modes, rate them, rank the risks and redesign for the highest ones. Faculty grade whether the ranking drives the recommendations, so a careful worksheet followed by unrelated fixes loses points. Cite FMEA methods and clinical evidence in APA 7. FMEA looks forward at what could fail, while root cause analysis looks back at what did. Priority scores are imperfect, so explain your ranking. A clear layout moves from team and process, to the worksheet, to the ranking, to the redesigns.

How this NURS 6223 Week 5 example is built

The team roster and a process map open the document: order, consent, specimen collection and labeling, crossmatch, release from the blood bank, transport, two-person bedside verification, and administration with monitoring. Beneath the map, a worksheet gives each step its failure modes, the effect on the patient, the likely causes and three ratings on ten-point scales for severity, occurrence and detection, multiplied into a risk priority number. Every rating is labeled as a team estimate. A ranking follows, and the narrative explains why two steps rate highest: a specimen labeled away from the bedside, and a verification performed by two people reading the same screen instead of the patient's band. Each high-ranked mode carries a redesign, the role accountable for it and a plan to rescore once the change is running.

Where the marks sit in the NURS 6223 Week 5 rubric

Proactive analysis is judged on whether the ranking drives the recommendations, and the common loss is a worksheet completed with care and then ignored. Criteria usually expect failure modes phrased as what could go wrong at a named step, not as general hazards, so a mode reading human error has told the reader nothing. Scoring earns credit when the scales are defined and the ratings attributed to a team, since a reader will otherwise ask who chose each number and on what basis. A narrative that notices the limits of the priority number tends to lift the analysis item. Recommendations are marked on strength and on fit to the top-ranked modes, and a plan addressing a low-ranked step first contradicts the document's own evidence. Missing rescoring plans cost less, though the loss is avoidable.

NURS 6223 Week 5 help: mistakes that cost marks

Failure modes analyses lose credit when recommendations ignore the ranking. Redesign the top risks first. Another common gap is a process map with missing steps. Walk through it with the team. Writers also rate scores without explanation. Note why each rating was chosen. Avoid relying only on priority numbers; severity alone can justify action. Name each team member's role. A redesign that removes a failure mode, such as barcode labeling at the bedside, ranks above one that adds a reminder. Show the expected new score after each redesign. Close with how you would test the redesign.

Get a NURS 6223 Week 5 example written to your instructions

Which process did your section assign? Name it, or take the transfusion pathway as a composite, and include the Week 5 template and rubric. The FMEA worksheet and narrative are delivered in 24-48h, the first free, scored on whichever scales your instructions define, with every rating labeled as a team estimate you can revise.

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NURS 6223 Week 5 questions, answered

How is a failure modes analysis different from a root cause analysis?

Direction. A root cause analysis starts from an event that happened and works backward to conditions; a failure modes analysis starts from a process and works forward to what could fail inside it. The sample analyzes transfusion before any error has occurred, which is why its evidence is team estimates rather than a timeline. Both methods can recommend redesign, but only one can prevent a first event.

Is the risk priority number reliable?

Useful rather than precise. It multiplies three ordinal ratings, so very different failure profiles can produce the same number, and a rare catastrophic mode can rank below a frequent nuisance. The sample uses the number to sort and then applies judgment, moving one high-severity mode up the list and saying why. Some healthcare versions of the method replace the product with a severity and probability matrix plus a decision tree.

Why transfusion as the example process?

Because its steps are well defined, its failures are serious and its checks are familiar to most nurses, which lets the analysis show scoring clearly. Any high-risk process with discrete steps would serve: chemotherapy administration, insulin infusion handoffs or specimen labeling. The chosen process should be narrow enough to map in one diagram, since a sprawling process yields too many rows to rank in any meaningful way.

Where can I find a free NURS 6223 Week 5 sample paper?

The blood administration failure modes analysis is shown here with the team, the worksheet, the ranking and the redesigns for the two highest risks.

Which two risks rank highest in NURS 6223 Week 5?

Sample labeling away from the bedside and identity checks at the bedside, which drive the barcode and two-person check redesigns.