Department/Division: NURSING

Process/Procedure: GENERAL ADMISSION CONTROL PROCEDURE

Conducted by:
Date Conducted:
FORMULA: Severity (S) x Likelihood (L) x Detection ( D ) = RPN
RISK and IMPACT/ CONSEQUENCE Identification

No. Activities Potential Risk Impacts/ Consequence

TRIAGING and May wrongfully tag the patient that will lead to delayed diagnosis and
1
Assessment Under-assessed Patient treatment.

Unreliable, incomplete personal data and

2 Data Gathering May not retrieve past records and can result to miss diagnosis
health history

RISK TABLE Matrix

Rating Severity Likelihood Detection
RISK Level
Negligible- managable by the Very Unlikely-Very
organization (e.g. Infrastructure slim or no chance at
1 Maintenance, delayed all; may only happen Very High - Evident or obvious LOW (L)
in exceptional occurrence of nonconformity
deliveries,Disqualification of
Accreditation,) circumstances

Unlikely- Could
Minor- it would take a considerable happen, but only
period to feel the effects, e.g. 1. rarely; once or few High – Needs certain level of
2 Equipment Breakdown, 2. Uncalibrated times in a decade, or verification/validation or MEDIUM (M)
Instruments, 3. Document/ Records improbable to occur engineering conttrol
Loss, 4. Low employee moral over the duration of
an activity
 Moderate- continuous activity without
controls may lead to non-conformity (e.g. Likely-Might happen
1. Customer Feedback, 2. Low Rating occasionally; once or Moderate - Detection controls
3 Performance 3. Poor services, 4. Poor few times a year; or have not been qualified/validated
may occur once to provide assurance of HIGH (H)
Quality of services, 5. Poor quality when an activity effectiveness.
supplied by supplier/ contractor, 6. High takes place
Attrition rate of employee...

Highly Probable-
Will probably occur Low - Detection Controls are
Serious- 1. High Revenue Loss, 2. Valid in most cases; either highly manual and/or historically
Customer Complaints, 3. Financial weekly, once or few unreliable.Current controls are
4
Implications are significant , 4. Property times a month; or inadequate to ensure failure
As much as po
loss 5. Negative Publicity may occur a few identification prior to further
times when activity processing.
takes place

Certain- Expected to
Major- 1. Loss of Life, 2. Loss of occur in most cases; Very Low –No detection control

5
Property, 3 Major Sanctions/Penalize, 4. either occurs daily,
several times per are possible . Acts only after the
Lost Benefits to Interested parties, 5. Civil day, or several times harm or impact has occurred or
Disobedience each time the no controls at all.
activity takes place
 RISKS AND OP
Document No.:
Reviewed by:
Date reviewed:
Next Review:
RPN Approved by:
Final R
Initial Risk Assessment

Control Resp. Implementation

Severity (S) Likelihood (L) Detection (D) Existing Controls RPN Risk Level Improvement Date

reassessment and Triage

Reassessment of
3 3 2 18 M frequent monitoring of nurse and Sept. 2024
patient after triage. patients after triage ER Nurse

Ask for 2 IDs, Properly Admitting

3 3 2 Ask for an ID Card 18 M communicate the need of Clerk, Sept. 2024
health history Nurse, MD

RISK BASED CONTROL PLAN

Action and Time Scale Value of Risk Priority Number

No additional controls are required. Consideration may be given to a more cost-

effective solution or improvement that imposes minimal additional cost burden. Less Than or Equal to 9
Monitoring is required to ensure that the controls are maintained.

Efforts should be made to reduce the risk, but the cost of prevention should be
carefully measured and limited. Risk reduction measures should be implemented 10 - 40
within a defined time period.
 Work should not be started until the risk has been reduced. Considerable
resources may have to be allocated to reduce the risk. Where the risk involves Greater than 40
work in progress, urgent action should be taken.

uch as possible the TARGET IS TO REDUCE THE RPN AFTER APPLYING CERTAIN CONTROLS to ACCEPTABLE Risk Level
RISKS AND OPPORTUNITIES ASSESSMENT FORM
Reviewed by:
Date reviewed:
Next Review:
Approved by:
FORMULA:
Final Risk Evaluation
Opportunity and IMPACT/Consequences Iden

RPN
Reference Severity (S) Likelihood (L) Detection (D) (SxLxD) Risk Level Potential Opportunity

Consultation
3 2 1 6 L Conduction of Training and Frequent Evaluation
Record

Consultation Establishment of Comprehensive Electronic

3 2 1 6 L
Record Record Keeping

Opportunity Table
Rating Impact
Number

Negligible- No percieved
value for improve output,
l to 9 1
service and customer
satisfaction

Minor- pursuing the

opportunity will slightly
2
improve output, service and
customer satisfaction
 Moderate- continuous activity
0 3 will improve output, service
and customer satisfaction

Significant- Continuous
activity will definitely impact
Risk Level 4
output, service and customer
satisfaction

Major- Continuous activity

will significantly improve
5
Output, Service and Customer
Satisfaction
 Impact (I) x Likelihood (L) x Degree of Sustainability( S ) = OPN
IMPACT/Consequences Identification

OPN
Impacts/ Consequence Impact (I) Likelihood (L) Sustainability (S) Existing Controls (IxLxS) Opp Level

Increases the Skills and Stimulates Critical Thinking of the Established Skill
5 3 4 60 A
Triage Nurse, thus providing high quality assessment. Building Programs

faster record retrieving thus saving time and resulting to Hiring of adequate
faster treatment and disposition 5 3 1 manpower on retrieving 15 S
health records

Opportunity Table
Opportunity Assessment
Likelihood Degree of Sustainability
Action and Time Scale

Very Unlikely-no chance Hard - Need significant Unacceptable

of success within the next resources to implement,
(U) No Action is required. Maintain Status Quo
12 months maintain and sustain

Unlikely-25% chance of
success within the next 12
months
 Difficult - Need certain
amount of investment and
Significant (S) May consider pursuing the opportunity
effort to maintain and
sustain

Likely-25-50% chance of
success within the next 12
months

Highly Probable- 51-75%

chance of success within
the next 12 months

Sustainable – Low
investment and resource is
required to maintain and Acceptable (A) Pursue the Opportunity
sustain improvement and
opportunity

Certain- 76-100% chance

of success within the next
12 months
OPN

Control Improvement Resp Reference

Establishing a committee on Training Training and

Training Certificates and
and development to ensure Development Evaluation Checklists
frequent monitoring and evaluation
committee

Utilization of available
resources. Minimally use of IT OPD/ER and Admission Logs
Excel to improve recording

ment (OPN)
Value of OPPORTUNITY Priority Number

Less Than or Equal to 9

 10 - 40

Greater than 40
Department/Division: NURSING
Process/Procedure: CLINICAL NURSING WARD PROCEDURE
Conducted by:
Date Conducted:
FORMULA: Severity (S) x Likelihood (L) x Detection ( D ) = RPN
RISK and IMPACT/ CONSEQUENCE Identification

No. Activities Potential Risk Impacts/ Consequence

May delay the course of treatment of the patient, and may also lead to
1 Assessment Under-assessed Patient miss diagnosis

2 Obtaining Vital Signs Unreliable patient condition May lead to miss diagnosis and miss treatment

3 Emergency Procedures (ACLS) Decreased patient outcome patient death

RISK TABLE Matrix

Rating Severity Likelihood Detection
RISK Level
Negligible- managable by the Very Unlikely-Very
organization (e.g. Infrastructure slim or no chance at
1 Maintenance, delayed all; may only happen Very High - Evident or obvious LOW (L)
in exceptional occurrence of nonconformity
deliveries,Disqualification of
Accreditation,) circumstances
 Unlikely- Could
Minor- it would take a considerable happen, but only
period to feel the effects, e.g. 1. rarely; once or few High – Needs certain level of
2 Equipment Breakdown, 2. Uncalibrated times in a decade, or verification/validation or MEDIUM (M)
Instruments, 3. Document/ Records improbable to occur engineering conttrol
Loss, 4. Low employee moral over the duration of
an activity

Moderate- continuous activity without

controls may lead to non-conformity (e.g. Likely-Might happen
1. Customer Feedback, 2. Low Rating occasionally; once or Moderate - Detection controls
3 Performance 3. Poor services, 4. Poor few times a year; or have not been qualified/validated
may occur once to provide assurance of HIGH (H)
Quality of services, 5. Poor quality when an activity effectiveness.
supplied by supplier/ contractor, 6. High takes place
Attrition rate of employee...

Highly Probable-
Will probably occur Low - Detection Controls are
Serious- 1. High Revenue Loss, 2. Valid in most cases; either highly manual and/or historically
Customer Complaints, 3. Financial weekly, once or few unreliable.Current controls are
4
Implications are significant , 4. Property times a month; or inadequate to ensure failure
As much as po
loss 5. Negative Publicity may occur a few identification prior to further
times when activity processing.
takes place
 Certain- Expected to
Major- 1. Loss of Life, 2. Loss of occur in most cases; Very Low –No detection control

5
Property, 3 Major Sanctions/Penalize, 4. either occurs daily,
several times per are possible . Acts only after the
Lost Benefits to Interested parties, 5. Civil day, or several times harm or impact has occurred or
Disobedience each time the no controls at all.
activity takes place
 RISKS AND OP
Document No.:
Reviewed by:
Date reviewed:
Next Review:
RPN Approved by:
Final R
Initial Risk Assessment

Control Resp. Implementation

Severity (S) Likelihood (L) Detection (D) Existing Controls RPN Risk Level Improvement Date

Frequent visiting patient Communicate with other staff

3 3 2 bedside to monitor and 18 M team members to Sept. 2024
evaluate patient response reevaluate patient. nurse

Replacement of Nurse,
Calibration of Existing and
5 3 3 Equipments once 45 H new equipments Supply Sept. 2024
worn office

Training
In service Skill and
Frequent Training and
5 4 4 80 H developme Sept. 2024
Building evaluation with simulation
nt
committee

RISK BASED CONTROL PLAN

Action and Time Scale Value of Risk Priority Number

No additional controls are required. Consideration may be given to a more cost-

effective solution or improvement that imposes minimal additional cost burden. Less Than or Equal to 9
Monitoring is required to ensure that the controls are maintained.
 Efforts should be made to reduce the risk, but the cost of prevention should be
carefully measured and limited. Risk reduction measures should be implemented 10 - 40
within a defined time period.

Work should not be started until the risk has been reduced. Considerable
resources may have to be allocated to reduce the risk. Where the risk involves Greater than 40
work in progress, urgent action should be taken.

uch as possible the TARGET IS TO REDUCE THE RPN AFTER APPLYING CERTAIN CONTROLS to ACCEPTABLE Risk Level
RISKS AND OPPORTUNITIES ASSESSMENT FORM
Reviewed by:
Date reviewed:
Next Review:
Approved by:
FORMULA:
Final Risk Evaluation
Opportunity and IMPACT/Consequences Iden

RPN
Reference Severity (S) Likelihood (L) Detection (D) (SxLxD) Risk Level Potential Opportunity

patient chart 3 2 1 6 L Conduction of Training and Frequent Evaluation

Defective and Frequent monitoring and reports of calibration

returned 3 2 2 12 M
Equipments Log of equipments

Attendance and
Certificates 3 2 1 6 L Establishment of Code Blue Team in every shift

Opportunity Table
Rating Impact
Number

Negligible- No percieved
value for improve output,
l to 9 1
service and customer
satisfaction
 Minor- pursuing the
opportunity will slightly
2
improve output, service and
customer satisfaction

Moderate- continuous activity

0 3 will improve output, service
and customer satisfaction

Significant- Continuous
activity will definitely impact
Risk Level 4
output, service and customer
satisfaction
 Major- Continuous activity
will significantly improve
5
Output, Service and Customer
Satisfaction
 Impact (I) x Likelihood (L) x Degree of Sustainability( S ) = OPN
IMPACT/Consequences Identification

OPN
Impacts/ Consequence Impact (I) Likelihood (L) Sustainability (S) Existing Controls (IxLxS) Opp Level

Increases the Skills and Stimulates Critical Thinking of the Established Skill
5 3 4 60 A
Nurse, thus providing high quality assessment. Building Programs

mapping and scheduling of calibration may increase the reporting of

detection of equipment in low performance, thus consider 5 3 2 malfunctioning and 30 S
not using them worn equipment

Promotes responsibility and proper navigating the Code

Schedule of duties,
team, thus increasing the capability of providing a quality 5 4 4 certificates 80 A
ACLS skills and management

Opportunity Table
Opportunity Assessment
Likelihood Degree of Sustainability
Action and Time Scale

Very Unlikely-no chance Hard - Need significant Unacceptable

of success within the next resources to implement,
(U) No Action is required. Maintain Status Quo
12 months maintain and sustain
 Unlikely-25% chance of
success within the next 12
months

Difficult - Need certain

amount of investment and
Significant (S) May consider pursuing the opportunity
effort to maintain and
sustain

Likely-25-50% chance of
success within the next 12
months

Highly Probable- 51-75%

chance of success within
the next 12 months

Sustainable – Low
investment and resource is
required to maintain and Acceptable (A) Pursue the Opportunity
sustain improvement and
opportunity
 required to maintain and Acceptable (A) Pursue the Opportunity
sustain improvement and
opportunity

Certain- 76-100% chance

of success within the next
12 months
OPN

Control Improvement Resp Reference

Establishing a committee on Training Training and

Training Certificates and
and development to ensure Development Evaluation Checklists
frequent monitoring and evaluation
committee

Establish a directory of third

party calibration agency supply office Calibration Logs

Establishment of bulletin of
Code Blue team Nursing Service Schedule

ment (OPN)
Value of OPPORTUNITY Priority Number

Less Than or Equal to 9

 10 - 40

Greater than 40
Greater than 40
Department/Division: PHU
Process/Procedure:
Conducted by:
Date Conducted:
FORMULA: Severity (S) x Likelihood (L) x Detection ( D ) = RPN
RISK and IMPACT/ CONSEQUENCE Identification

No. Activities Potential Risk Impacts/ Consequence

Delayed approval of proposals due to lack of

1 Activity Proposal May struggle to fully implement the program
fund

Implementation of Surveillance
2 and reporting of notifiable Missed or delayed case detection Untimely reporting of consolidated data of detected cases
diseases

Failure to notify the receiving facility in Delayed readiness of medical team may lead to delayed medical response and possible
3 Communication during referrals
advance deterioration of patient condition

RISK TABLE Matrix

Rating Severity Likelihood Detection
RISK Level
Negligible- managable by the Very Unlikely-Very
organization (e.g. Infrastructure slim or no chance at
1 Maintenance, delayed all; may only happen Very High - Evident or obvious LOW (L)
in exceptional occurrence of nonconformity
deliveries,Disqualification of
Accreditation,) circumstances
 Unlikely- Could
Minor- it would take a considerable happen, but only
period to feel the effects, e.g. 1. rarely; once or few High – Needs certain level of
2 Equipment Breakdown, 2. Uncalibrated times in a decade, or verification/validation or MEDIUM (M)
Instruments, 3. Document/ Records improbable to occur engineering conttrol
Loss, 4. Low employee moral over the duration of
an activity

Moderate- continuous activity without

controls may lead to non-conformity (e.g. Likely-Might happen
1. Customer Feedback, 2. Low Rating occasionally; once or Moderate - Detection controls
3 Performance 3. Poor services, 4. Poor few times a year; or have not been qualified/validated
may occur once to provide assurance of HIGH (H)
Quality of services, 5. Poor quality when an activity effectiveness.
supplied by supplier/ contractor, 6. High takes place
Attrition rate of employee...

Highly Probable-
Will probably occur Low - Detection Controls are
Serious- 1. High Revenue Loss, 2. Valid in most cases; either highly manual and/or historically
Customer Complaints, 3. Financial weekly, once or few unreliable.Current controls are
4
Implications are significant , 4. Property times a month; or inadequate to ensure failure
As much as po
loss 5. Negative Publicity may occur a few identification prior to further
times when activity processing.
takes place
 Certain- Expected to
Major- 1. Loss of Life, 2. Loss of occur in most cases; Very Low –No detection control

5
Property, 3 Major Sanctions/Penalize, 4. either occurs daily,
several times per are possible . Acts only after the
Lost Benefits to Interested parties, 5. Civil day, or several times harm or impact has occurred or
Disobedience each time the no controls at all.
activity takes place
 RISKS AND OP
Document No.:
Reviewed by:
Date reviewed:
Next Review:
RPN Approved by:
Final R
Initial Risk Assessment

Control Resp. Implementation

Severity (S) Likelihood (L) Detection (D) Existing Controls RPN Risk Level Improvement Date

Engage LGUs and NGOs for Follow up the approval of PHU

3 3 4 funding support 36 M the proposal Coordinator Sept. 2024

Standardized case detection Disease

Involvement of other staffs in protocols in-service
3 3 3 different areas in reporting 27 M awareness to disease Survellance Sept. 2024
surveillance Unit

PHU
4 4 4 Verbal Feedback 64 H Feedback Form Utilization
head/Coord Sept. 2024

RISK BASED CONTROL PLAN

Action and Time Scale Value of Risk Priority Number

No additional controls are required. Consideration may be given to a more cost-

effective solution or improvement that imposes minimal additional cost burden. Less Than or Equal to 9
Monitoring is required to ensure that the controls are maintained.
 Efforts should be made to reduce the risk, but the cost of prevention should be
carefully measured and limited. Risk reduction measures should be implemented 10 - 40
within a defined time period.

Work should not be started until the risk has been reduced. Considerable
resources may have to be allocated to reduce the risk. Where the risk involves Greater than 40
work in progress, urgent action should be taken.

uch as possible the TARGET IS TO REDUCE THE RPN AFTER APPLYING CERTAIN CONTROLS to ACCEPTABLE Risk Level
RISKS AND OPPORTUNITIES ASSESSMENT FORM
Reviewed by:
Date reviewed:
Next Review:
Approved by:
FORMULA:
Final Risk Evaluation
Opportunity and IMPACT/Consequences Iden

RPN
Reference Severity (S) Likelihood (L) Detection (D) (SxLxD) Risk Level Potential Opportunity
Approved
Involvement of external agencies in the
Activity 2 2 2 8 L
implementation of activities
Proposal

Surveillance Training for more staffs to decrease risk of

2 2 2 8 L
Reporting Form missing reporting

Referral form 2 2 2 8 L Formulation of Policies and Procedures

Opportunity Table
Rating Impact
Number

Negligible- No percieved
value for improve output,
l to 9 1
service and customer
satisfaction
 Minor- pursuing the
opportunity will slightly
2
improve output, service and
customer satisfaction

Moderate- continuous activity

0 3 will improve output, service
and customer satisfaction

Significant- Continuous
activity will definitely impact
Risk Level 4
output, service and customer
satisfaction
 Major- Continuous activity
will significantly improve
5
Output, Service and Customer
Satisfaction
 Impact (I) x Likelihood (L) x Degree of Sustainability( S ) = OPN
IMPACT/Consequences Identification

OPN
Impacts/ Consequence Impact (I) Likelihood (L) Sustainability (S) Existing Controls (IxLxS) Opp Level

Request for
broader scope and higher chances of implementation 3 4 3 36 A
Assistance

In-service awareness to
reporting is more efficient 3 3 3 disease surveillance 27 S

dissemination of Policies
referral routinely efficient, properly documented and in order 4 4 4 and Procedures via MOA 64 A

Opportunity Table
Opportunity Assessment
Likelihood Degree of Sustainability
Action and Time Scale

Very Unlikely-no chance Hard - Need significant Unacceptable

of success within the next resources to implement,
(U) No Action is required. Maintain Status Quo
12 months maintain and sustain
 Unlikely-25% chance of
success within the next 12
months

Difficult - Need certain

amount of investment and
Significant (S) May consider pursuing the opportunity
effort to maintain and
sustain

Likely-25-50% chance of
success within the next 12
months

Highly Probable- 51-75%

chance of success within
the next 12 months

Sustainable – Low
investment and resource is
required to maintain and Acceptable (A) Pursue the Opportunity
sustain improvement and
opportunity
 required to maintain and Acceptable (A) Pursue the Opportunity
sustain improvement and
opportunity

Certain- 76-100% chance

of success within the next
12 months
OPN

Control Improvement Resp Reference

district health zone meeting

PHU Head/ MOA
Coord

disease
train more personnel
request letter for training,
surveilance certificate
unit

District Health Zone Meeting PHU Head/ Coord MOA, Communication Letter

ment (OPN)
Value of OPPORTUNITY Priority Number

Less Than or Equal to 9

 10 - 40

Greater than 40
Greater than 40