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Abi AXDCF, Cruz EDDA, Pontes L, Santos TD, Felix JVC. The Healthcare Failure Mode and Effect Analysis as a tool to evaluate care protocols. Rev Bras Enferm 2022; 75:e20210153. [DOI: 10.1590/0034-7167-2021-0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 09/14/2021] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objectives: to identify, classify, and analyze modes of failure in the medication process. Methods: evaluative research that used the Healthcare Failure Mode and Effect Analysis (HFMEA) in a service of bone marrow transplant from June to September 2018, with the participation of 35 health workers. Results: 207 modes of failure were identified and classified as mistakes in verification (14%), scheduling (25.6%), administration (29%), dilution (16.4%), prescription (2.4%), and identification (12.6%). The analysis of risk showed a moderate (51.7%) and high (30.9%) need of intervention, leading to the creation of an internal quality assurance group and of continued education activities. Conclusions: the Healthcare Failure Mode and Effect Analysis showed itself to be a tool to actively identify, classify, and analyze failures in the process of medication, contributing for the proposal of actions aimed at patient safety.
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Santos PRAD, Rocha FLR, Sampaio CSJC. Actions for safety in the prescription, use and administration of medications in emergency care units. ACTA ACUST UNITED AC 2019; 40:e20180347. [PMID: 31038608 DOI: 10.1590/1983-1447.2019.20180347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/16/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify what risks and incidents related to the drug therapy process are presented in an Emergency Care Unit (UPA) and to present proposals for management actions and safe practices, in the perception of the nursing team. METHOD Qualitative research, in the research-action modality, developed in the scenario of UPA, located in the interior of São Paulo. Data collection was done through interviews and focus groups with 33 professionals, between June 2015 and April 2016. For the data treatment, the Content Analysis Technique was used. RESULTS AND DISCUSSION From the participants' reports, thematic categories were organized, with the risks and incidents related to the drug therapy process being one of the listed categories, as well as proposals for actions. CONCLUSION The study allowed the implementation of patient safety actions related to the administration of drugs in a PAU, offering a higher quality of care.
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Affiliation(s)
- Patricia Reis Alves Dos Santos
- Universidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto, Programa de Pós- Graduação Mestrado Profissional Tecnologia e Inovação em Enfermagem. Ribeirão Preto, São Paulo, Brasil
| | - Fernanda Ludmilla Rossi Rocha
- Universidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto, Programa de Pós- Graduação Mestrado Profissional Tecnologia e Inovação em Enfermagem. Ribeirão Preto, São Paulo, Brasil
| | - Camila Santana Justo Cintra Sampaio
- Universidade de São Paulo (USP), Escola de Enfermagem de Ribeirão Preto, Programa de Pós-Graduação em Enfermagem Fundamental. Ribeirão Preto, São Paulo, Brasil
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Costa DGD, Pasin SS, Magalhães AMMD, Moura GMSSD, Rosso CB, Saurin TA. Analysis of the preparation and administration of medications in the hospital context based on Lean thinking. ESCOLA ANNA NERY 2018. [DOI: 10.1590/2177-9465-ean-2017-0402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Objectives: To analyze the current way medications are prepared and administered in the hospital setting and to apply a method to establish priorities for problems detected. Method: This is an exploratory-descriptive case study. The data were collected through observation and focus groups with 13 participants who were part of a health team in a surgical inpatient unit of a public university hospital. The analysis was based on a lean production framework. Results: A value stream map was constructed of the current way drugs are prepared and administered, identifying the clients in the process and their requirements. Forty-five current problems were identified, based on requirements that were not met with eight being prioritized to improve planning. Conclusion: Having prioritized the problems, the planning and implementation of continuous improvements in the medication process were started in order to reduce errors and improve the quality of services.
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Pires ADOM, Ferreira MBG, do Nascimento KG, Felix MMDS, Pires PDS, Barbosa MH. Elaboration and Validation of the Medication Prescription Safety Checklist. Rev Lat Am Enfermagem 2017; 25:e2921. [PMID: 28793128 PMCID: PMC5626178 DOI: 10.1590/1518-8345.1817.2921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 05/11/2017] [Indexed: 11/21/2022] Open
Abstract
Objective to elaborate and validate a checklist to identify compliance with the recommendations for the structure of medication prescriptions, based on the Protocol of the Ministry of Health and the Brazilian Health Surveillance Agency. Method methodological research, conducted through the validation and reliability analysis process, using a sample of 27 electronic prescriptions. Results the analyses confirmed the content validity and reliability of the tool. The content validity, obtained by expert assessment, was considered satisfactory as it covered items that represent the compliance with the recommendations regarding the structure of the medication prescriptions. The reliability, assessed through interrater agreement, was excellent (ICC=1.00) and showed perfect agreement (K=1.00). Conclusion the Medication Prescription Safety Checklist showed to be a valid and reliable tool for the group studied. We hope that this study can contribute to the prevention of adverse events, as well as to the improvement of care quality and safety in medication use.
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Affiliation(s)
| | | | | | - Márcia Marques dos Santos Felix
- Doctoral student, Universidade Federal do Triângulo Mineiro, Uberaba,
MG, Brazil. Scholarship holder at Coordenação de Aperfeiçoamento de Pessoal de Nível
Superior (CAPES), Brazil
| | - Patrícia da Silva Pires
- PhD, Adjunct Professor, Instituto Multidisciplinar em Saúde,
Universidade Federal da Bahia, Vitória da Conquista, BA, Brazil
| | - Maria Helena Barbosa
- PhD, Associate Professor, Universidade Federal do Triângulo Mineiro,
Uberaba, MG, Brazil
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Volpe CRG, Melo EMMD, Aguiar LBD, Pinho DLM, Stival MM. Risk factors for medication errors in the electronic and manual prescription. Rev Lat Am Enfermagem 2016; 24:e2742. [PMID: 27508913 PMCID: PMC4990040 DOI: 10.1590/1518-8345.0642.2742] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 08/28/2015] [Indexed: 11/23/2022] Open
Abstract
Objective: to compare electronic and manual prescriptions of a public hospital of Brasilia,
identifying risk factors for the occurrence of medication errors. Method: descriptive-exploratory, comparative and retrospective study. Data collection
occurred from July 2012 to January 2013, using an instrument for the review of the
information contained in medical records related to the medication process. A
total of 190 manual and 199 electronic records composed the sample, with 2027
prescriptions each. Results: compared to the manual prescription, a significant reduction was observed in the
risk factors after implantation of the electronic prescription, in items such as
"lack of the form of dilution" (71.1% to 22.3%) and "prescription with brand name"
(99.5% to 31.5%). Conversely, the risk factors "no check" and "lack of CRM of the
prescriber" increased. The lack of the allergy registration and the occurrences
related to medication were the same for both groups. Conclusion: generally, the use of the electronic prescription system was associated with a
significant reduction in risk factors for medication errors, concerning the
following aspects: illegibility, prescription with brand name and presence of
essential items that provide a safe and effective prescription.
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Affiliation(s)
- Cris Renata Grou Volpe
- PhD, Adjunct Professor, Faculdade de Ceilândia, Universidade de Brasília, Brasília, DF, Brazil
| | - Eveline Maria Magalhães de Melo
- Undergraduate student in Nursing, Faculdade de Ceilândia, Universidade de Brasília, Brasília, DF, Brasil. Scholarship holder of the Universidade de Brasília, Brasília, DF, Brasil
| | - Lucas Barbosa de Aguiar
- Undergraduate student in Nursing, Faculdade de Ceilândia, Universidade de Brasília, Brasília, DF, Brasil. Scholarship holder of the Universidade de Brasília, Brasília, DF, Brasil
| | - Diana Lúcia Moura Pinho
- PhD, Adjunct Professor, Faculdade de Ceilândia, Universidade de Brasília, Brasília, DF, Brazil
| | - Marina Morato Stival
- PhD, Adjunct Professor, Faculdade de Ceilândia, Universidade de Brasília, Brasília, DF, Brazil
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Bloch-Teitelbaum A, Lüde S, Rauber-Lüthy C, Kupferschmidt H, Russmann S, Kullak-Ublick GA, Ceschi A. Medication wrong route administration: a poisons center-based study. Expert Opin Drug Saf 2013; 12:145-52. [PMID: 23421948 DOI: 10.1517/14740338.2013.770468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe clinical effects, circumstances of occurrence, management and outcomes of cases of inadvertent administration of medications by an incorrect parenteral route. METHODS Retrospective single-center consecutive review of parenteral route errors of medications, reported to our center between January 2006 and June 2010. We collected demographic data and information on medications, route and time of administration, severity of symptoms/signs, treatment, and outcome. RESULTS Seventy-eight cases (68 adults, 10 children) were available for analysis. The following wrong administration routes were recorded: paravenous (51%), intravenous (33%), subcutaneous (8%), and others (8%). Medications most frequently involved were iodinated x-ray contrast media (11%) and iron infusions (9%). Twenty-eight percent of the patients were asymptomatic and 54% showed mild symptoms; moderate and severe symptoms were observed in 9% and 7.7%, respectively, and were mostly due to intravenous administration errors. There was no fatal outcome. In most symptomatic cases local nonspecific treatment was performed. CONCLUSIONS Enquiries concerning administration of medicines by an incorrect parenteral route were rare, and mainly involved iodinated x-ray contrast media and iron infusions. Most events occurred in adults and showed a benign clinical course. Although the majority of exposures concerned the paravenous route, the occasional severe cases were observed mainly after inadvertent intravenous administration.
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Affiliation(s)
- Alexandra Bloch-Teitelbaum
- Associated Institute of the University of Zurich, Swiss Toxicological Information Centre, Zurich, Switzerland
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Silva AEBDC, Cassiani SHDB. Prospective risk analysis of the anti-infective medication administration process. Rev Lat Am Enfermagem 2013; 21 Spec No:233-41. [DOI: 10.1590/s0104-11692013000700029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 10/10/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: The objective of this study was to analyze the potential risks involved in the administration process of intravenous anti-infective medication at a medical clinic, using the Failure Mode and Effect Analysis. METHOD: This exploratory study was conducted at the medical clinic of a hospital in the State of Goiás. For data collection we convened a team comprised of six professionals involved in medication treatment: a doctor, nurse, nursing technician, pharmacist, a nursing and a risk manager. A total of 24 meetings were held, for a total of 56 hours. The data were transcribed into an electronic database within Microsoft Excel®, and the Xfmea4 software was used. RESULT: The results indicated 52 failure modes, 79 effects of failure, and 285 causes of failure. The causes were related to: the management of organizational processes, human resources, physical and material structure. A total of 298 actions for improvement were recommended for 215 causes of high and average priority, 81.9% of which were short-term priorities. The simulation of the impact of the proposed interventions revealed a 79.7% reduction of the high-priority failure modes. CONCLUSION: It was concluded that the study identified potential risks to patients and recommended proactive actions, of rapid application and low cost, evaluated positively in the reduction of risk of occurrence of avoidable incidents, increasing reliability and safety of the medication administration process. Studies like this demonstrate that, with the application of a method of risk analysis, nurses can effectively assist in preventing medication incidents.
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