Survey on risks of epinephrine use in children and its prevention strategies
10.3760/cma.j.issn.1008-5734.2018.05.007
- VernacularTitle:儿童肾上腺素临床用药风险调查及防范策略研究
- Author:
Yali SHI
1
;
Xing JI
;
Huilei GUO
;
Ying LI
;
Mingmei ZHU
;
Xuan WANG
;
Jing XU
Author Information
1. 210008,南京医科大学附属儿童医院药剂科
- Publication Type:Journal Article
- Keywords:
Healthcare failure mode and effect analysis;
Epinephrine;
Risk managment
- From:
Adverse Drug Reactions Journal
2018;20(5):353-358
- CountryChina
- Language:Chinese
-
Abstract:
Objective To investigate the risks of epinephrine use in children using healthcare failure mode and effect analysis (HFMEA) method.Methods A project team was set up and data on adverse events of epinephrine use in children reported at home and abroad,data of medication errors in database of clinical medication safety monitoring network,and data from questionnaires and on-the-spot investigations were collected.Risk points in the process of epinephrine use were collected using HFMEA method.Severity (S),frequency of occurrence (O),and likelihood of detection(D) of risks were scored (the scores ranged from 1.0 to 5.0) and the risk priority numbers (RPN) were determined.The risk points with higher RPN scores or the score of severity up to 5.0 were screened out and the corresponding prevention strategies were formulated.Results Through comprehensive evaluation on data from domestic and foreign databases and medication error databases in clinical medication safety monitoring network,as well as data from questionnaires and on-the-spot investigations,a total of 33 risk points in links of hospital information system,doctor prescribing,pharmacist dispensing,and nurse dispensing were obtained.Fourteen risk points with higher RPN scores and the score of severity up to 5.0 were screened out,including 2,4,4,and 4 risk points in links of hospital information system,doctor prescribing,pharmacist dispensing,and nurse dispensing,respectively.Fourteen preventive strategies corresponding to the risk points were established,including 6 mandatory,4 recom-mended,and 4 conditional ones.Conclusion Risk points were found in the process of epinephrine use in children by HFMEA method and unified management standards were established.
