Failure mode and effects analysis to reduce risk of heparin use.
Purpose Failure mode and effects analysis (FMEA) was used to identify safety risks of unfractionated heparin (UFH) use and to develop and implement countermeasures to improve safety. Methods FMEA was used to analyze the transportation, preparation, dispensation, administration, therapeutic monitorin...
| Publicado en: | American Journal of Health-System Pharmacy Vol. 76; no. 23; pp. 1972 - 1980 |
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| Autores principales: | , , , , |
| Formato: | research tables/charts Journal Article |
| Publicado: |
Oxford University Press / USA
12/1/2019
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=139643685&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 139643685 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 10792082 1X3 jtl: American Journal of Health-System Pharmacy issn: 10792082 maglogo: N pubinfo: dt: 12/1/2019 vid: 76 iid: 23 pid: 622 pub: Oxford University Press / USA artinfo: ui: 139643685 139643685 139643685 10.1093/ajhp/zxz229 139643685 ppf: 1972 ppct: 8 formats: fmt: – @attributes: type: T – @attributes: type: P tig: atl: Failure mode and effects analysis to reduce risk of heparin use. aug: au: Pino, Felicity A Weidemann, Darcy K Schroeder, Lisa L Pabst, Damon B Kennedy, Audrey R affil: Children's Mercy, Kansas City, MO, and Assistant Professor, School of Medicine and Bloch School of Management, University of Missouri-Kansas City, Kansas City, MO sug: subj: Heparin Adverse Effects Adverse Drug Event Risk Factors Adverse Drug Event Prevention and Control Risk Assessment Patient Safety Human Drug Compounding Drug Administration Routes Drug Monitoring Medical Waste Disposal Tertiary Health Care Hospitals, Pediatric Stakeholder Participation Medical Countermeasures ab: Purpose Failure mode and effects analysis (FMEA) was used to identify safety risks of unfractionated heparin (UFH) use and to develop and implement countermeasures to improve safety. Methods FMEA was used to analyze the transportation, preparation, dispensation, administration, therapeutic monitoring, and disposal of UFH in a tertiary care, freestanding pediatric hospital. The FMEA was conducted in a stepwise fashion. First, frontline staff mapped the different steps within the UFH use process. Next, key stakeholders identified potential failures of each process step. Finally, using calibrated scales, the stakeholders ranked the likelihood of occurrence, severity, and detectability for each potential failure's cause. The rankings were used to prioritize high-risk areas on which to focus efforts for improvement countermeasures. Results The analysis revealed 233 potential failures and 737 unique potential causes. After ranking of all identified potential causes, 45 were deemed high scoring. Those 45 causes were further refined into 13 underlying contributing causes. To address the contributing causes, selected team members developed 22 countermeasures. The FMEA showed that implementation of the countermeasures reduced the level of mathematical risk. Conclusion FMEA was helpful in identifying, ranking, and prioritizing medication risks in the UFH use process. Twenty-two countermeasures were developed to reduce potential for error in the riskiest steps of the process. pubtype: Academic Journal doctype: research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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