Use of failure mode, effect and criticality analysis to improve safety in the medication administration process

• DOI: 10.1111/jep.12314
• Publication Date: 2015-04-02T22:18:53Z
• Authors: Carmen Guadalupe ...; Maria Luisa Marti...; Ana Herranz‐Alonso; Maria Isabel Dura...; Paloma Hernandez‐...; Maria Sanjurjo‐Saez
• Keywords: Medication Systems, Hospital; Safety Management; Process Assessment, Health Care; Gastroenterology; Nursing Staff, Hospital; Quality Improvement; 3. Good health; 03 medical and health sciences; 0302 clinical medicine; Spain; Humans; Medication Errors; Health Services Research

To critically evaluate the causes of preventable adverse drug events during nurse medication administration process in inpatient units with computerized prescription order entry and profiled automated dispensing cabinets to prioritize interventions that need be implemented impact specific on criticality index.This is a failure mode, effects analysis (FMECA) study. A multidisciplinary consensus committee composed pharmacists, nurses doctors evaluated administering medications hospital setting Spain. By analysing process, all modes were identified was determined by rating severity, frequency likelihood detection scale 1 10, using adapted versions already published scales. Safety strategies prioritized.Through consensus, eight processes 40 modes, which 20 classified as high risk. The sum indices 5254. For potential high-risk 21 different found resulting 24 recommendations. Thirteen recommendations prioritized developed over 24-month period, reducing total from 5254 3572 (a 32.0% reduction). greater development an electronic record (-582) standardization intravenous compounding unit (-168). Other improvements, such barcode technology (-1033), scheduled for longer period time because lower feasibility.FMECA useful approach can improve process.