Use of failure mode effect analysis (FMEA) to improve medication management process

Abstract

Purpose Medication management is a complex process, at high risk of error with life threatening consequences. The focus should be on devising strategies to avoid errors and make the process self-reliable by ensuring prevention of errors and/or error detection at subsequent stages. The purpose of this paper is to use failure mode effect analysis (FMEA), a systematic proactive tool, to identify the likelihood and the causes for the process to fail at various steps and prioritise them to devise risk reduction strategies to improve patient safety. Design/methodology/approach The study was designed as an observational analytical study of medication management process in the inpatient area of a multi-speciality hospital in Gurgaon, Haryana, India. A team was made to study the complex process of medication management in the hospital. FMEA tool was used. Corrective actions were developed based on the prioritised failure modes which were implemented and monitored. Findings The percentage distribution of medication errors as per the observation made by the team was found to be maximum of transcription errors (37 per cent) followed by administration errors (29 per cent) indicating the need to identify the causes and effects of their occurrence. In all, 11 failure modes were identified out of which major five were prioritised based on the risk priority number (RPN). The process was repeated after corrective actions were taken which resulted in about 40 per cent (average) and around 60 per cent reduction in the RPN of prioritised failure modes. Research limitations/implications FMEA is a time consuming process and requires a multidisciplinary team which has good understanding of the process being analysed. FMEA only helps in identifying the possibilities of a process to fail, it does not eliminate them, additional efforts are required to develop action plans and implement them. Frank discussion and agreement among the team members is required not only for successfully conducing FMEA but also for implementing the corrective actions. Practical implications FMEA is an effective proactive risk-assessment tool and is a continuous process which can be continued in phases. The corrective actions taken resulted in reduction in RPN, subjected to further evaluation and usage by others depending on the facility type. Originality/value The application of the tool helped the hospital in identifying failures in medication management process, thereby prioritising and correcting them leading to improvement.

Peran Metode Failure Mode and Effect Analysis (FMEA) terhadap Mutu Pelayanan Rumah Sakit: Systematik Review

“…Artikel ke empat penggunaan metode FMEA pada proses pelayanan manajemen pengobatan di Rawat inap rumah sakit. Sehingga disimpulkan FMEA merupakan alat penilaian resiko yang efektif digunakan sehingga mengurangi kejadian medication error dan proses manajemen obat yang aman untuk pasien (Jain, 2017).…”

“…Penelitian tentang penggunaan metode FMEA pada pelayanan farmasi FMEA merupakan alat penilaian risiko yang efektif digunakan sehingga mengurangi sebesar 50-60% kejadian medication error dan proses manajemen obat yang aman untuk pasien (Jain, 2017). Ofek et al, (2016) tentang penggunaan metode FMEA pada proses pelayanan dalam pemberian KCL di rumah sakit, FMEA mampu untuk meningkatkan proaktif keamanan dan proses yang efesien di sistem pelayanan kesehatan.…”

Análise de falhas e efeitos na preparação e dispensação de quimioterápicos

“…Esta herramienta se usa en la industria para evaluar de forma proactiva los posibles fallos en un determinado proceso (13,14) y ha pasado por varias actualizaciones, siendo ampliamente utilizada en diversas industrias, como la industria aeroespacial y la automotriz, entre otras. El Healthcare Failure Mode and Effects Analysis (HFMEA) es un sistema simplificado y adaptado del Análisis Multimodal de Fallos y sus Efectos (AMFE) al área de la salud.…”

“…Permite la identificación proactiva de las vulnerabilidades del sistema de atención a la salud. Se basa en el concepto de que un riesgo no sólo debe valorarse en función de la probabilidad con la que se produce sino también con la gravedad de sus consecuencias (13,14) . Tras la identificación y análisis de los modos de fallo, sus efectos y sus causas, se establecen recomendaciones y se dan prioridades a las intervenciones con el propósito de identificar los cambios necesarios para eliminar o reducir el riesgo de posible fallo.…”

Problems of use of FMEA method in industrial enterprise

“…The analysis of FMEA is particularly recommended in the development and production of a new product, as it allows identification of potential defects in time that they can be eliminated by the use of preventive measures before the start of production. The method can be applied not only to analyze the causes of defects already identified, but also in order to prevent defects that are likely to occur in the product (Jain, 2017).…”