RESUMEN
OBJECTIVE:To reduce the error rate of homing the withdrawn drugs in pharmacy intravenous admixture service (PIVAS). METHODS:Using risk priority(RPN),the potential failure modes for links of homing the withdrawn drugs in PIVAS were evaluated by using failure mode and effects analysis (FMEA) method. Combining with the links of homing the withdrawn drugs,the reasons for errors were investigated,the feasible scheme to reduce error rates was proposed and the intervention effect was evaluated after 3 months. RESULTS:In the PIVAS links of homing the withdrawn drugs,8 high-risk failure modes had been found in total,such as poor double check system(RPN was 100),unfamiliarity of seemingly drugs(RPN was 36),a large num-ber of the withdrawn drugs(RPN was 20),etc. Thus,risk control measures had been formulated,including reinforcing the double check system,optimizing the management system of PIVAS and so on. After 3 months of intervention management,RPN of the first 3 items were reduced to 20,16,8;error rate of homing the withdrawn drugs was reduced from 1.98% to 0.62%(P<0.05). CONCLUSIONS:The application of FMEA management method in PIVAS of our hospital has reduced the error rate of homing the withdrawn drugs.
RESUMEN
OBJECTIVE:To reduce the error rate of homing the withdrawn drugs in pharmacy intravenous admixture service (PIVAS). METHODS:Using risk priority(RPN),the potential failure modes for links of homing the withdrawn drugs in PIVAS were evaluated by using failure mode and effects analysis (FMEA) method. Combining with the links of homing the withdrawn drugs,the reasons for errors were investigated,the feasible scheme to reduce error rates was proposed and the intervention effect was evaluated after 3 months. RESULTS:In the PIVAS links of homing the withdrawn drugs,8 high-risk failure modes had been found in total,such as poor double check system(RPN was 100),unfamiliarity of seemingly drugs(RPN was 36),a large num-ber of the withdrawn drugs(RPN was 20),etc. Thus,risk control measures had been formulated,including reinforcing the double check system,optimizing the management system of PIVAS and so on. After 3 months of intervention management,RPN of the first 3 items were reduced to 20,16,8;error rate of homing the withdrawn drugs was reduced from 1.98% to 0.62%(P<0.05). CONCLUSIONS:The application of FMEA management method in PIVAS of our hospital has reduced the error rate of homing the withdrawn drugs.