Management strategy study on hypertonic glucose injection (≥ 20％) based on failure mode and effect analysis
10.3760/cma.j.issn.1008-5734.2018.05.005
- VernacularTitle:基于失效模式和效应分析的高渗葡萄糖注射液(浓度≥20％)管理策略研究
- Author:
Yiping WANG
1
;
Kan QIN
;
Fang LIU
;
Siyuan CHEN
;
Luyan FAN
Author Information
1. 230061,合肥市第一人民医院药学部
- Publication Type:Journal Article
- Keywords:
Healthcare failure mode and effect analysis;
Glucose solution,hypertonic;
Hospital administration;
High-alert medicine
- From:
Adverse Drug Reactions Journal
2018;20(5):340-345
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze the risks of hypertonic glucose injection (20％) (hypertonic glucose) in clinical application using failure mode and effect analysis (FMEA) method and improve the relevant management measures.Methods A study group on risk prevention strategies of hypertonic glucose was established in the First People's Hospital of Hefei.Domestic and foreign literature on medication error cases,preventive measures or management strategies,and data from questionnaires and on-the-spot investigations were collected.The failure modes in the process of hypertonic glucose application were analyzed and assessed.Severity (S),frequency of occurrence (O),and likelihood of detection (D) of the risks related to these failure modes were scored and the risk priority numbers (RPN) were determined.The failure modes with higher RPN were screened out and the corresponding prevention strategies were formulated.The incidence of medication errors and potential hazards,cognition rate of knowledge on drugs,qualification rate of drug storage,and satisfaction rate for management measures before and after the improvement were analyzed comparatively.Results According to the results from literature search,questionnaires,and on-the-spot investigations,a total of 24 failure modes were found in the 6 links relevant with hypertonic glucose application in clinical,which included links of prescription writing and delivery,pharmacist dispensing,nurse dispensing,post-administration monitoring,drug management,and information technology.Ranking the RPN from high to low,7 major failure modes with higher RPN were selected from the 24 failure modes,including the existence of drugs with similar name and drugs with similar package,wrong drug dispensing,absence of post-administration monitoring,lack of marked labels for drugs,garbles caused by lack of medication knowledge,and untimely record and report of medication errors.The incidences of medication errors and potential safety hazards before and after management improvement were 3.2％ (7/216) and 0.4％ (1/234),respectively and the difference had no statistical significance (P =0.058).The average cognitive rates of physicians,nurses and pharmacists before and after the improvement were 65.2％ (15/23),54.2％ (13/24),67.9％ (19/28) and 95.8％ (23/24),91.7％ (22/24),95.5 ％ (21/22),respectively and the differences were statistically significant (P 50.05 for all).The qualification rates of drug storage before and after management improvement were 70.2％ (151/215) and 98.7％ (230/ 233),respectively and the difference was statistically significant (P 5 0.05).The average satisfaction degrees of medical staff with hyperosmotic glucose management were 81.3％ (61/75) and 95.7％ (65/70),respectively before and after the management improvement and the difference was statistically significant (P 5 0.05).Conclusion Failure modes in the process of hypertonic glucose use can be effectively identified using the FMEA method,and the risk events can be effectively reduced after the corresponding improvement measures.
