Promoting the Safety Management of Heparin Sodium Injection Used for Children by HFMEA Method / 中国药房

ABSTRACT

OBJECTIVE:To promote the safe use of Heparin sodium injection for children. METHODS:According to litera-ture retrieve,questionnaire survey and field investigation,Health care failure mode and effect analysis method(HFMEA)was ad-opted to search for the failure modes of Heparin sodium injection for children,and preventive strategies were established and imple-mented based on these failure modes. Its effects were evaluated by comparing the error rate and risk priority number rating (RPN value)before and after the implementation. RESULTS:Totally 5 risk points of Heparin sodium injection requiring immediate inter-vention were obtained from RPN value,including wrong dose of Heparin sodium injection in prescribing,pharmacists'unclearness for the calculation method of the dose of Heparin sodium injection in dispensing,and nurses'no performing of double check sys-tem before infusion in administration,etc. After implementing related countermeasures,related error of Heparin sodium injection was decreased from 8 cases to 1 case,and error rate was declined from 3.76% to 0.51%(P<0.01). The RPN values of 5 failure modes were decreased from 112.08,91.56,115.78,94.52,99.23 to 28.02,23.91,27.71,23.63,20.55,respectively. CONCLU-SIONSHFMEA can prospectively conduct systematical analysis for Heparin sodium injection for children. Implementing related countermeasures based on the current situation of our hospital can reduce the related error of Heparin sodium injection and promote the medication safety of children.