Onkologie. 2021:15(4):197-203 | DOI: 10.36290/xon.2021.039

FMEA used for the risk control in healthcare

Iva Brabcová1, Radka Prokešová2, Valérie Tóthová1, Hana Hajduchová1, Ivana Chloubová1, Jan Neugebauer1, Květoslava Slabáková1, Dana Velimská1, Edita Klavíková1, Hana Kubešová1
1 Jihočeská univerzita v Českých Budějovicích, Zdravotně sociální fakulta, Ústav ošetřovatelství, porodní asistence a neodkladné péče, České Budějovice
2 Jihočeská univerzita v Českých Budějovicích, Zdravotně sociální fakulta, Ústav humanitních studií v pomáhajících profesích, České Budějovice

The goal of the study was to identify and assess the risks in the process of medicament administration by nurses.

Methodology: The empiric study was designed as a quantitative method using focus groups. 22 managers from 4 hospitals in South Bohemia took part in the focus groups. The process of medicament administration by nurses was analyzed using the FMEA method.

Results: In the process of drug administration, 28 possible failure modes with 12 identifiable causes were identified. The mean value of the Risk Priority Number (RPN) was 97, the RPN was higher than 125 in six failure modes. They included the risk of medication errors, missed out drug administration, wrong ordering of oral drug administration, missed out comparison of the patient`s ID with the healthcare records, generic medication error made by a nurse, and missed out hand hygiene. The preventive measures minimalizing the risks associated with drug administration include the introduction of a complete system of electronic medicament prescription which is, at the same time, interconnected with the Positive List of Hospital Medicaments, the introduction of regular internal audits of keeping complete records on medicaments in the healthcare records.

Keywords: management, FMEA, drug/medicament administration, risk, healthcare.

Published: September 1, 2021  Show citation

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Brabcová I, Prokešová R, Tóthová V, Hajduchová H, Chloubová I, Neugebauer J, et al.. FMEA used for the risk control in healthcare. Onkologie. 2021;15(4):197-203. doi: 10.36290/xon.2021.039.
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References

  1. Carroll RL. Risk management handbook for health care organizations. San Francisco: Jossey-Bass, 2009: 672 s.
  2. Šupšáková P. Řízení rizik při poskytování zdravotních služeb. Praha: Grada, 2017: 260 s.
  3. Huertas-Fernández MJ, Martínez-Bautista MJ, Rodríguez-Mateos ME, et al. Implementation of safeguards to improve patient safety in chemotherapy. Clinical and Translational Oncology 2017; 19(9): 1099-1106. Go to original source... Go to PubMed...
  4. Pokorná A, et al. Management nežádoucích událostí ve zdravotnictví. Praha: Grada, 2019: 247 s.
  5. Kullberg A, Larsen J, Sharp L. "Why is there another person"s name on my infusion bag?' Patient safety in chemotherapy care - A review of the literature. European Journal of Oncology Nursing 2013; 17(2): 228-235. Go to original source... Go to PubMed...
  6. Byers JF, White SV. Patient safety: Principles and practice. New Yourk: Springer, 2004: 554 s.
  7. Feleke SA, Mulatu MA, Yesmaw AS. Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC Nursing 2015; 14(1): 53. Go to original source... Go to PubMed...
  8. Kruer R, Jarrell A, Latif A. Reducing medication errors in critical care: a multimodal approach. Clin Pharmacol. 2014; 6: 117-126. Go to original source... Go to PubMed...
  9. Khushboo J. Use of failure mode effect analysis (FMEA) to improve medication management process. International Journal of Health Care Quality Assurance 2017; 30(2): 175-186. Go to original source... Go to PubMed...
  10. Ashley L, Armitage G. Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. J Patient Saf 2010; 6(4): 210-215. Go to original source... Go to PubMed...
  11. Aranaz-Andrés JM, Bermejo-Vicedo T, Muñoz-Ojeda I, et al. Failure mode and effects analysis applied to the administration of liquid medication by oral syringes. Farm Hosp 2017; 41(6): 674-677. Go to PubMed...
  12. Brabcová I, Bártlová S, et al. Management v ošetřovatelské praxi. Praha: NLN. 2015: 286 s.
  13. Žaloudek A. Management kvality a rizik psychiatrické péče. Praha: Grada, 2020: 248 s.
  14. Vyhláška č. 329/2019 Sb., o předepisování léčivých přípravků při poskytování zdravotních služeb, v platném znění.
  15. Zákon č. 378/2007 Sb., o léčivech a o změnách některých souvisejících zákonů (zákon o léčivech).
  16. Zákon č. 372/2011 Sb., o zdravotních službách a podmínkách jejich poskytování (zákon o zdravotních službách), v platném znění.
  17. SAK. Akreditační standardy pro nemocnice. [online] Spojená akreditační komise, 2014 [cit. 2020-01-02]. Dostupné z: https://www.sakcr.cz/files/2e6e410b84857cf84cf734275644446f/nemsak-standardy-nemocnice-2014.pdf
  18. MZČR. Minimální požadavky na pro zavedení interního systému hodnocení kvality a bezpečí poskytovaných zdravotních služeb. [online]. MZČR, 2015 [cit. 2021-01-02]. Dostupné z: https://www.mzcr.cz/wp-content/uploads/wepub/10927/36163/V%C4%9Bstn%C3%ADk%20MZ%20%C4%8CR%2016-2015.pdf
  19. Li G, Xu B, He R, Zhang S. Using Healthcare Failure Mode and Effect Analysis to Reduce Intravenous Chemotherapy Errors in Chinese Hospitalized Patients. Cancer Nursing 2017; 40(2): 88-93. Go to original source... Go to PubMed...
  20. Baldwin A, Rodriguez E. Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses. Clinical Journal of Oncology Nursing 2016; 20(1): 59-65. Go to original source... Go to PubMed...
  21. Zákon č. 96/2004 Sb., o podmínkách získávání a uznávání způsobilosti k výkonu nelékařských zdravotnických povolání a k výkonu činností souvisejících s poskytováním zdravotní péče, v platném znění.
  22. Jin H, Chen H, Munechika M et al. The effect of workload on nurses' non-observance errors in medication administration processes: A cross-sectional study. Intl J Nurs Pract 2018; 24(5): e12679. Go to original source... Go to PubMed...
  23. Gorgich EAC, Barfroshan S, Ghoreishi G et al. Investigating the Causes of Medication Errors and Strategies to Prevention of Them from Nurses and Nursing Student Viewpoint. Global Journal of Health Science 2015; 8(8): 2020-227. Go to original source... Go to PubMed...
  24. Zákon č. 185/2001 Sb., o odpadech a změně některých dalších zákonů.
  25. Wagner C, Smiths M, Sorra J, Huang CC. Assessing patient safety culture in hospitals across countries. International Journal for Quality in Health Care 2013: 1-9. Go to original source... Go to PubMed...




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