Risk assessment of drug management process in women surgery department of qaem educational hospital [QEH] using HFMEA method [2013]

Evaluation and improvement of drug management process are essential for patient safety. The present study was performed whit the aim of assessing risk of drug management process in Women Surgery Department of QEH using HFMEA method in 2013. A mixed method was used to analyze failure modes and their effects with HFMEA. To classify failure modes; nursing errors in clinical management model, for classifying factors affecting error; approved model by the UK National Health System, and for determining solutions for improvement; Theory of Inventive Problem Solving, were used. 48 failure modes were identified for 14 sub-process of five steps drug management process. The frequency of failure modes were as follow: 35.3% in supplying step, 20.75% in prescription step, 10.4% in preparing step, 22.9% in distribution step and 10.35% in follow up and monitoring step. Seventeen failure modes [35.14%] were considered as non-acceptable risk [hazard score = 8] and were transferred to decision tree. Among 51 Influencing factors, the most common reasons for error were related to environmental factors [21.5%], and the less common reasons for error were related to patient factors [4.3%]. HFMEA is a useful tool to evaluating, prioritization and analyzing failure modes in drug management process. Revision drug management process based focus-PDCA, assessing adverse drug reactions [ADR], USE patient identification bracelet, holding periodical pharmaceutical conferences to improve personnel knowledge, patient contribution in drug therapy; are performance solutions which were placed in work order

Proactive risk assessment of the laboratory management process in Ghaem Hospital, Mashhad [2013]

Laboratory errors may occur in every stage of laboratory management process and lead to a considerable harm to inpatients. This study was aim to investigate the Proactive risk assessment of the laboratory management process in Ghaem Hospital, Mashhad [2013]. This was a descriptive research that quantitatively and qualitatively analyzed some failure modes and effects. In order to classify the modes of failure and effective causes of them and also determining the improvement strategies, we have used "nursing error management association", "Eindhoven" and "theory of inventive problem solving" models respectively. In 5 steps of laboratory management process which is conducted on17 listed sub-processes, on average 59 error modes in each ward was identified. 18.7% of error modes were identified as high risk errors [hazard score >/= 8]. Most of error causes were related to human factors [42.7%].In addition, 31.6% of preventive measures were assigned in human resources management strategy group and 16.9% in team work group. The Healthcare Failure Mode and Effect Analysis method was very efficient in identifying failure modes, determining causes which impact each failure mode, and proposing improvement strategies for laboratory management processes of Ghaem Department

Health Care Failure Mode and Effect Analysis: a Useful Proactive Risk Analysis of Nutrition and Food Distribution in Mashhad Qaem Hospital's Women's Surgery Ward in 2013

Good medical nutrition therapy [MNT] is crucial to inpatients' health and treatment, and is part of routine hospital cares. Surgery ward is a highly danger-prone section in any hospital. The present study was conducted for a proactive risk analysis of nutrition and food distribution in Mashhad Qaem Hospital' Women's Surgery Ward in 2013 through health care failure mode and effect analysis [HFMEA]. A qualitative-quantitative research identified and analyzed the failure modes and effects through HFMEA. To rank error modes, we drew upon nursing errors in the clinical management model; to rank the effective causes of failure, we approved the model by the UK National Health System; and to rank the performance improvement approaches, we used the theory of inventive problem solving, TRIZ [theory of inventive problem solving]. A total of 42 failure modes were identified for 15 sub-processes listed in 7 processes of nutrition and food distribution. In sum, 11.9% of the failures modes were classified as high risk [hazard scores >=8]. Of 15 effective failure modes, the highest number of cause failure modes was associated with team factors, and the lowest number was associated with facilities. Using proactive HFMEA is highly effective in detecting potential failures in medication, effective factors in failure modes, and performance improvement approaches in hospital food distribution. [Monitoring proper patient-wards relationship], [committee establishment on diet, nutrition and medications], [performance assessment checklist making] and [supervising by nutrition authority over food distribution in wards] were identified as effective performance approaches in the Women's Surgery Ward in Qaem Hospital