Management strategy study on medication errors of concentrated potassium chloride injection based on failure mode and effect analysis
10.3760/cma.j.issn.1008-5734.2019.05.005
- VernacularTitle:基于失效模式与效应分析的浓氯化钾注射液用药错误防范策略研究
- Author:
Wenya SHAN
1
;
Saiping JIANG
;
Fang LIU
;
Xiaoyang LU
Author Information
1. 浙江大学附属第一医院药学部,杭州,310003
- Publication Type:Journal Article
- Keywords:
Healthcare failure mode and effect analysis;
Potassium chloride;
Medication errors;
Risk management;
High alert medications
- From:
Adverse Drug Reactions Journal
2019;21(5):334-338
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze the risks of high alert drug concentrated potassium chloride injection in clinical application using failure mode and effect analysis (FMEA) method and make the relevant prevention measures.Methods A study team was established in the First Affiliated Hospital,Zhejiang University.The risk points in the application process of concentrated potassium chloride injection through literature search,questionnaires,and on-the-spot investigations were collected.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 RPN ＞ 10.0 or their severity up to 5.0 were screened out and the corresponding prevention strategies were formulated.Results Five risk points were collected through literature search;10 risk points were obtained through questionnaires,including 3 from physicians,3 from pharmacists,and 4 from nurses;and 5 risk points were obtained through on-the-spot investigations.Sixteen risk points with RPN ＞ 10.0 or severity up to 5.0 were further screened from the above links,including 3 from information system links,2 from drug storage links,4 from doctor prescription links,4 from pharmacist dispensing links,and 3 from nurse administration links.According to the selected risk points,22 prevention strategies were formulated.The prevention measures for the above 5 links were 4,4,6,5,and 3,respectively,including 11 mandatory strategies,9 recommended strategies,and 2 conditional strategies.Conclusion The risk points of concentrated potassium chloride injection application can be screened using FMEA method,which is helpful to formulate the preventive strategies for medication errors related to the drug.
