Many of the catastrophic errors in health care are related to inadequate procedures. Robust preventative actions are therefore required to minimize the risks inherent to the prescribing, dispensing and administration of medicines. The redesigning of subsystem processes is a goal that should be undertaken to improve the overall safety of hospitals. Many organizations are beginning to apply traditional aerospace engineering methodologies to the study of patient safety. In a hospital setting, the pharmacy department is responsible for the procurement, distribution, and control of all medicines used within the organization. Pharmacists should ensure that medicines are delivered to patient care areas in a safe and secure manner and that they are available to the administration within a time frame that meets the essential needs of patients. A Failure mode analysis applied to pharmaceutical distribution has been carried out in the S.G.Battista Hospital in Turin (Italy), from the receiving of the goods stage to the delivery to the departments. Two main high risk activities have been identified from risk matrices and risk priority number analysis. The first activity concerns the picking and packing phases and the second one is due to the low efficiency of the random controls of pharmacists. The analysis has also pointed out some medium risk activities in the refill request control, storage temperature control and consignment to delivery service departments. The present analysis has offered the opportunity of quantifying safety within a specific hospital environment and of designing feasible corrective actions. The real effectiveness of the proposed actions will be verified during a subsequent experimental phase.
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