Table 1

Study phases

Phase IPhase IIPhase IIIPhase IV
Qualitative dataQuantitative dataScoringRanking
Identify and list potential failures (effects and causes)Medical record review (n=100)Harm (H)
Frequency (F)
Detection (D)
Top ranked CIs
Example: max (H=7)×(F=10)=70
Six participant sessions
  • DM history and medication

  • Incidence of hypo/hyperglycaemia postdischarge (30 days)

  • Endocrinology or Certified Diabetes Educator consultation prior to discharge

  • Discharge regimen

  • Outpatient follow-up with endocrinology clinic (phone calls and complete visits, 30 days)

  • Readmissions (30 days, 1 year, n=50 patients)

  • Rejection and infection (1 year, n=50 patients)

See table 2.
Diabetes mellitus scoring sheet
Top ranked RPNs
Example: max (H=7)×(F=10)×(D=10)=700
Create process map Scoring Scale
High/best: 1
Low/worst: 10
Assign root causes
Joint Commission Classifications
Direct observations Criticality Index (CI)
(H)×(F) scores
Patient tracers Risk Priority Number (RPN)
(H)×(F)×(D) scores
  • DM, diabetes mellitus.