Use of failure modes and effects analysis to mitigate potential risks prior to implementation of an intravenous compounding technology.
Purpose The purpose of this study was to identify potential failure points in a new chemotherapy preparation technology and to implement changes that prevent or minimize the consequences of those failures before they occur using the failure modes and effects analysis (FMEA) approach. Methods An FMEA...
| Publicado en: | American Journal of Health-System Pharmacy Vol. 78; no. 14; pp. 1323 - 1330 |
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| Autores principales: | , , , , |
| Formato: | research tables/charts Journal Article |
| Publicado: |
Oxford University Press / USA
7/15/2021
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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=151353986&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 151353986 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: 7/15/2021 vid: 78 iid: 14 pid: 622 pub: Oxford University Press / USA artinfo: ui: 151353986 151353986 151353986 10.1093/ajhp/zxab179 151353986 ppf: 1323 ppct: 7 formats: fmt: @attributes: type: P tig: atl: Use of failure modes and effects analysis to mitigate potential risks prior to implementation of an intravenous compounding technology. aug: au: Feemster, Agnes Ann Augustino, Melissa Duncan, Rosemary Khandoobhai, Anand Rowcliffe, Meghan affil: Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, MD sug: subj: Drug Compounding Medication Errors Prevention and Control Risk Assessment Technology Administration, Intravenous Systems Analysis Human Process Assessment (Health Care) Workflow Patient Safety ab: Purpose The purpose of this study was to identify potential failure points in a new chemotherapy preparation technology and to implement changes that prevent or minimize the consequences of those failures before they occur using the failure modes and effects analysis (FMEA) approach. Methods An FMEA was conducted by a team of medication safety pharmacists, oncology pharmacists and technicians, leadership from informatics, investigational drug, and medication safety services, and representatives from the technology vendor. Failure modes were scored using both Risk Priority Number (RPN) and Risk Hazard Index (RHI) scores. Results The chemotherapy preparation workflow was defined in a 41-step process with 16 failure modes. The RPN and RHI scores were identical for each failure mode because all failure modes were considered detectable. Five failure modes, all attributable to user error, were deemed to pose the highest risk. Mitigation strategies and system changes were identified for 2 failure modes, with subsequent system modifications resulting in reduced risk. Conclusion The FMEA was a useful tool for risk mitigation and workflow optimization prior to implementation of an intravenous compounding technology. The process of conducting this study served as a collaborative and proactive approach to reducing the potential for medication errors upon adoption of new technology into the chemotherapy preparation process. pubtype: Academic Journal doctype: research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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