Failure Mode and Effects Analysis (FMEA) Risk Analysis Example Acupuncture Needles Flow Charts
Inspect needles Load needles into autoclave bags Load autoclave Run program Unload autoclave Transfer bags to packaging
Process Step
Mode Kegagalan
Akibat Patient injury bruise Patient injury broken needle under skin
Sev 1-3
Penyebab Insufficient sampling plan Operator error (missed defect) Insufficient sampling plan Operator error (missed defect) Insufficient sampling plan
Controls
Prob 1-3
Risk Index
Saran Tindakan
Provide training and visual guidance on inspection techniques
Inspection
Defective needle is missed
Provide training and visual guidance on inspection techniques
Unusable needle
Operator error (missed defect) Document states to distribute load evenly Bioburden QC testing Document provides load/program matrix Bioburden QC testing Document provides load/program matrix Operator Error Visual inspection during packaging/ assembly operation Lot file review includes equipment printout review Bioburden QC testing
Provide training and visual guidance on inspection techniques Add load diagram to document Validate bioburden test method Validate load capacities Validate bioburden test method Validate load capacity
Load is not balanced
Incomplete sterilization
Operator Error
Load autoclave
Unit is overloaded
Incomplete sterilization
Operator Error
Unit is underloaded
Deformed needle housing unusable needle
Incorrect program is selected Run autoclave program
Incomplete sterilization
Fix batch sizes and use a single program Validate bioburden test method
Operator Error
Entire cycle is not run Cycle does not meet max temperature
Incomplete sterilization Incomplete sterilization
Equipment failure Power failure Equipment is out of calibration
Preventive maintenance Connect to emergency generator; allow repeat run
Annual calibration check
Run each cycle with biological indicators