| Failure mode (What could/does go wrong) | Type of failure | Effect (Outcome from failure) | L | S | D | RPN |
|---|---|---|---|---|---|---|
| Lack of identified role for all team members in a Code C-section. | Latent |
| 10 | 8 | 9 | 720 |
| Inconsistent process of ordering and receiving blood products and lab results | Latent |
| 10 | 10 | 7 | 700 |
| Lack of closed-loop communication with lab/blood bank | Active |
| 10 | 10 | 6 | 600 |
| Nonstandardized communication between RN, OB, and NNP regarding clinical status | Active |
| 8 | 8 | 9 | 576 |
| “Dead spaces” noted when Code C-section is called overhead | Latent |
| 10 | 9 | 5 | 450 |
| Failure to use common language in calling Code C-section | Active |
| 4 | 5 | 9 | 180 |
| Drugs for treatment of hemorrhage are not located in same place | Latent |
| 10 | 8 | 1 | 80 |
| Anesthesiologist in OR not able to talk directly with the lab/blood Bank | Latent |
| 10 | 4 | 1 | 40 |
| Neonatal resuscitation needs not standardized among NNPs | Active |
| 5 | 8 | 1 | 40 |
| Interpreter services utilized in variable ways | Latent |
| 8 | 5 | 1 | 40 |
L = likelihood; S = severity; D = discoverability; RPN = risk priority number; C-section = cesarean section; RN = registered nurse; OB = obstetrician; NNP = neonatal nurse practitioner; OR = operating room.
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