Study on the risk point of medication errors of insulin degludec based on failure mode and effect analysis
10.3760/cma.j.cn114015-20220816-00751
- VernacularTitle:基于失效模式和效应分析的德谷胰岛素用药错误风险点研究
- Author:
Xinyu WANG
1
;
Hui YU
;
Zhiyan YANG
;
Yundi ZHANG
;
Yue LI
;
Yan LI
Author Information
1. 山东中医药大学药学院，济南 250355
- Publication Type:Journal Article
- Keywords:
Failure mode and effect analysis;
Insulin degludec;
Medication errors;
Risk management;
Security measures
- From:
Adverse Drug Reactions Journal
2023;25(4):237-242
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To explore the risks of medication errors of insulin degludec (IDeg) in clinical application using failure mode and effect analysis (FMEA).Methods:A research group on the risk points of medication errors was established in the First Affiliated Hospital of Shandong First Medical University. The risk points of medication errors were collected through questionnaire survey, literature research, and on-the-spot investigation. The severity, frequency of occurrence, and likelihood of detection were scored to determine the risk priority number (RPN) and formulate corresponding preventive measures.Results:After comprehensive evaluation, 32 risk points were found in the 4 links of physician prescription, pharmacist dispensing, nurse administration, and patient medication. The RPN was ranked from high to low, and 10 key risk points (RPN>70 points) were selected. (1) The pharmacist did not give the patients guidance on the use of IDeg; (2) Patients did not know that they should actively report to the physicians about the use feeling and adverse reactions of the drug; (3) Patients did not clear about the content of medication monitoring; (4) Patients did not master how to use the drug; (5) Pharmacists did not conduct medication feedback survey on patients; (6) Patients did not attach importance or thought it was unnecessary to receive medication guidance from pharmacists; (7) Physician′s prescription was wrong, resulting in overdose; (8) Doctors and patients did not communicate well, and patients did not know what medicine they were using; (9) Pharmacists did not fully understand drug information such as drug properties, prohibited population, interaction, medication time, etc.; (10) Pharmacists ignored the commonly used dose of the drug, applicable population, and other information in the process of reviewing the prescription. According to above-mentioned risk points, the risk intervention suggestions of IDeg were put forward, including the maintenance of basic drug information, the prescription of doctors, the dispensing of pharmacists, the patient medication link, the nurse administration link, the collection of medication error reports, and the strengthening of personnel training.Conclusion:The FMEA method can be used to effectively find out the risk points of medication errors in the clinical application of IDeg, the priority of IDeg risk management can be determined through quantitative evaluation, and corresponding preventive measures can be formulated.
