Study on risk points of medication errors in potassium permanganate external preparation by failure mode and effect analysis
10.3760/cma.j.issn.1008-5734.2019.02.009
- VernacularTitle:基于失效模式和效应分析的高锰酸钾外用制剂用药错误风险点研究
- Author:
Rong FAN
1
;
Sisi YUAN
;
Helen ZHANG
Author Information
1. 北京和睦家医院药剂科 100015
- Publication Type:Journal Article
- Keywords:
Healthcare failure mode and effect analysis;
Potassium permanganate;
Medication errors;
Risk management;
Security measures
- From:
Adverse Drug Reactions Journal
2019;21(2):123-128
- CountryChina
- Language:Chinese
-
Abstract:
Objective To explore the risk points of medication errors of potassium permanganate external preparation in clinical application using Failure Mode and Effect Analysis (FEMA) method.Methods A study group on prevention strategies of medication errors in potassium permanganate external preparation was set up in Beijing United Family Healthcare and Beijing Obstetrics and Gynecology Hospital.Failure modes and risk points were collected through literature review,questionnaire survey and on-the-spot investigation.Severity (S),frequency of occurrence (O),and likelihood of detection (D) of the failure modes and risk points were scored and their risk priority numbers (RPN) were determined.Failure modes and risk points with PRN scores ＞ 150 were defined as high risk points and corresponding prevention strategies were formulated.Results According to the literature reports,medication errors in potassium permanganate external preparation occurred mainly in the link of patient medication,and the main place was the patient's home.After comprehensive evaluation,a total of 20 risk points in 6 circulation links (physician prescription,drug dispensing,medication administration by nurses,and patient medication) of potassium permanganate external preparation were found,of which 9 risk points were with RPN ＞ 150.They were as follows:(1) the potassium permanganate external tablets looked similar to the oral tablets and were easy to be taken orally by mistake;(2) there were no striking tips of "For External Use Only" and "External Use After Dilution " on drug packages;(3) high concentrations of external tablets or powder could be directly exposed to skin;(4) drug dilution concentration was guided by solution color;(5) patients did not know how to use the drug due to inadequate information communication;(6) failure to clearly inform patients how to use potassium permanganate external preparation and the precautions;(7) hospital information system did not remind the drug dilution method;(8) target concentration after dilution was not noted in the prescription;(9) the patient's body or clothing might be dyed during medication.Conclusion FMEA method could effectively identify risk points of potassium permanganate external preparation in clinical application,help medical institutions formulate management strategies,and guarantee the medication safety in patients.
