Failure mode and effect analysis in the preparation and dispensation of chemotherapy

Authors

DOI: https://doi.org/10.6018/eglobal.389551
Keywords: Healthcare Failure Mode and Effect Analysis, Patient Safety, Medication Errors

Abstract

Aim: Conduct a Failure Mode and Effect Analysis (FMEA) to prospectively identify the risks related to the preparation and dispensation of chemotherapy drugs at an outpatient unit of a reference center in oncology.
Methods: The first six stages of Failure Mode and Effect Analysis were used to identify dangerous situations and assemble a team; define the process to be analyzed and describe it graphically; apply a host of ideas to identify failure modes; prioritize failure modes and conduct risk analysis; identify potential causes of failure modes and redesign the process.
Results: Seventeen failure modes were identified, two of which were classified as high risk: changing the output window for the drug and miscalculating the intrathecal drug dose.
Conclusions: The possible failure modes related to the process analyzed were identified; in addition, it was possible to define potential causes of these risks.

Downloads

Download data is not yet available.

Author Biographies

Priscila Cumba de Abreu Costa , Universidade Federal do Rio Grande do Norte

Mestre em Gestão da Qualidade em Serviços de Saúde. Universidade Federal do Rio Grande do Norte, Departamento de Saúde Coletiva. Enfermeira. Natal/RN, Brasil.

Vilani Medeiros de Araújo Nunes, Universidade Federal do Rio Grande do Norte

Doutora em Ciências da Saúde. Universidade Federal do Rio Grande do Norte, Departamento de Saúde Coletiva. Professora Adjunta. Natal/RN, Brasil.

Thiago da Silva Bezerra, Universidade Federal do Rio Frande do Norte

Graduando em Medicina. Universidade Federal do Rio Grande do Norte, Centro de Ciências da Saúde. Natal/RN, Brasil.

Grasiela Piuvezam, Universidade Federal do Rio Grande do Norte

Doutora em Ciências da Saúde. Universidade Federal do Rio Grande do Norte, Departamento de Saúde Coletiva. Professora Adjunta. Natal/RN, Brasil

Zenewton André da Silva Gama, Universidade Federal do Rio Grande do Norte

Doutor em Saúde Pública. Universidade Federal do Rio Grande do Norte, Departamento de Saúde Coletiva. Professor Adjunto. Natal/RN, Brasil.

References

National Patient Safety Foundation. Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After “To Err Is Human”. Boston: National Patient Safety Foundation; 2015 [access: 05 mar 2018]. Available from: http://www.ihi.org/resources/Pages/Publications/Free-from-Harm-Accelerating-Patient-Safety-Improvement.aspx

Sousa P, Uva AS, Serranheira F, Nunes C, Leite ES. Estimating the incidence of adverse events in Portuguese hospitals: a contribution to improving quality and patient safety. BMC Health Serv Res [serial on the Internet]. 2014 [access: 22 out 2018];14(1):311. Available from: https://doi.org/10.1186/1472-6963-14-311

World Health Organization. Marco Conceptual de la Classificación Internacional para la Seguridad del Paciente, version 1.1. Geneva: WHO/IER/PSP; 2009 [access: 05 mar 2018]. Available from: http://www.who.int/patientsafety/implementation/icps/icps_full_report_es.pdf

Santos J da SD, Almeida PHRF, Rosa MB, Perini E, Pádua CAM de, Lemos G da S. Prescription and Administration Errors Involving a Potentially Dangerous Medicine. J Nurs UFPE line [periódico na Internet]. 2017 [acesso: 05 mar 2018];11(10). Disponível em: https://doi.org/10.5205/1981-8963-v11i10a13807p3707-3717-2017

Mendes W, Pavão ALB, Martins M, Moura MLO, Travassos C. The feature of preventable adverse events in hospitals in the State of Rio de Janeiro, Brazil. Rev Assoc Med Bras [periódico na Internet]. 2013 [acesso: 05 mar 2018];59(5). Disponível em: https://doi.org/10.1016/j.ramb.2013.03.002

Costa NN, de Camargo Silva AEB, de Lima JC, de Sousa MR, Barbosa JSDF, Bezerra ALQ. O retrato dos eventos adversos em uma clínica médica: análise de uma década. Cogitare enferm [periódico na Internet]. 2016 [acesso: 22 out 2018];21(5): 01-10. Disponível em: http://dx.doi.org/10.5380/ce.v21i5.45661

Mattsson TO, Holm B, Michelsen H, Knudsen JL, Brixen K, Herrstedt J. Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study. Ann Oncol [serial on the Internet]. 2015 [access: 22 out 2018];26(5):981–6. Available from: https://doi.org/10.1093/annonc/mdv032

Weingart SN, Zhang L, Sweeney M, Hassett M. Chemotherapy medication errors. Lancet Oncol [serial on the Internet]. 2018 [access: 22 out 2018 ];19(4):e191–9. Available from: https://doi.org/10.1016/S1470-2045(18)30094-9

Raban MZ, Westbrook JI. Are interventions to reduce interruptions and errors during medication administration effective?: A systematic review [serial on the Internet]. BMJ Qual Saf. 2014 [access : 05 mar 2018]. 23. Available from: https://doi.org/10.1136/bmjqs-2013-002118

Michaelson M, Walsh E, Bradley CP, McCague P, Owens R, Sahm LJ. Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital. Ir J Med Sci [serial on the Internet]. 2017 [access: 05 mar 2018]; 186(3): [about 6 p.]. Available from: https://doi.org/10.1007/s11845-017-1556-5

Keers RN, Williams SD, Cooke J, Ashcroft DM. Prevalence and Nature of Medication Administration Errors in Health Care Settings: A Systematic Review of Direct Observational Evidence. Ann Pharmacother [serial on the Internet]. 2013 [access: 22 out 2018];47(2):237–56. Available from: https://doi.org/10.1345/aph.1R147

Instituto para Práticas Seguras no Uso de Medicamentos. Antineoplásicos parenterais: erros de medicação, riscos e práticas seguras na utilização. Belo Horizonte: ISMP; 2014 [acesso: 05 mar 2018]. Disponível em: http://www.ismp-brasil.org/site/wp-content/uploads/2015/07/V3N3.pdf

Polancich S, Rue L, Poe T, Miltner R. Proactive Risk Mitigation: Using Failure Modes and Effects Analysis for Evaluating Vascular Access. J Healthc Qual [serial on the Internet]. 2018 [access: 05 mar 2018]; 40(1). Available from: https://doi.org/10.1097/JHQ.0000000000000125

Jain K. Use of failure mode effect analysis (FMEA) to improve medication management process. Int J Health Care Qual Assur [serial on the Internet]. 2017 [access: 5 mar 2018];30(2). Available from: https://doi.org/10.1108/IJHCQA-09-2015-0113

Joint Commission Resources Inc. Failure Mode and Effects Analysis in Health Care: proactive risk reduction. Oakbrook Terrace (IL): Joint Commission Resources; 2010.

DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using Health Care Failure Mode and Effect AnalysisTM: The VA National Center for Patient Safety’s Prospective Risk Analysis System. Jt Comm J Qual Improv [serial on the Internet]. 2002 [access: 05 mar 2018];28(5). Available from: https://doi.org/10.1016/S1070-3241(02)28025-6

Li G, Xu B, He R., Zhang S. Using Healthcare Failure Mode and Effect Analysis to Reduce Intravenous Chemotherapy Errors in Chinese Hospitalized Patients. Cancer Nurs [serial on the Internet]. 2017 [access: 22 out 2018]; 40(2):88–93. Available from: http://dx.doi.org/10.1097/ncc.0000000000000348

Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs [serial on the Internet]. 2014 [access: 22 out 2018];37(4):299–309. Available from: http://dx.doi.org/10.1097/NCC.0000000000000108

Camerini FG, Colcher AP, Moraes DS, Souza DL, Vasconcelos JR, Neves RO. Fatores de risco para ocorrência de erro no preparo de medicamentos endovenosos: uma revisão integrativa. Cogitare Enferm [períodico na Internet]. 2014 [acesso: 05 mar 2018]; 19(2). Disponível em: http://dx.doi.org/10.5380/ce.v19i2.37362

Forte ECN, Machado FL, Pires DEP. A relação da enfermagem com os erros de medicação: uma revisão integrativa. Cogitare Enferm [períodico na Internet]. 2016 [acesso: 05 mar 2018]; 21. Disponível em: http://dx.doi.org/10.5380/ce.v21i5.43324

Silva BA, Marques IB, Brasil POR, Cardoso AFRC, Pinto MNFB, Souza MMT. O trabalho da enfermagem no âmbito do SUS - estudo reflexivo. R. Flu Exten Univ [periódico na Internet] 2017 [acesso: 05 mar 2018]; 07(1). Disponível em: http://editorauss.uss.br/index.php/RFEU/article/view/914/pdf

Teixeira TCA, De Bortoli CSH. Análise de causa raiz de acidentes por quedas e erros de medicação em hospital. ACTA Paul Enferm [periódico na Internet]. 2014 [acesso: 05 mar 2018]; 27(2). Disponível em: http://dx.doi.org/10.1590/1982-0194201400019

Marini DC, Pinheiro JT, Integradas F, Imaculada M, Paula R. Avaliação dos erros de diluição de medicamentos de administração intravenosa em ambiente hospitalar para o desenvolvimento de um guia de diluição e administração dos mesmos. Infarma - Ciências Farm [periódico na Internet]. 2016 [acesso: 05 mar 2018];28(2). Disponível em: http://dx.doi.org/10.14450/2318-9312.v28.e2.a2016.pp81-89

Brasil. Agência Nacional de Vigilância Sanitária. Resolução RDC N.º 45, de 12 de março de 2003. Dispõe sobre o Regulamento Técnico de Boas Práticas de Utilização das Soluções Parenterais (SP) em Serviços de Saúde. Brasília: ANVISA; 2003 [acesso: 05 mar 2018]. Disponível em: https://www20.anvisa.gov.br/segurancadopaciente/index.php/legislacao/item/resolucao-rdc-n-45-de-12-de-marco-de-2003

McElroy LM, Khorzad R, Nannicelli AP, Brown AR, Ladner DP, Holl JL. Failure mode and effects analysis: A comparison of two common risk prioritisation methods. 2016 [access: 22 out 2018];25(5):329–36. Available from: http://dx.doi.org/10.1136/bmjqs-2015-004130

Published
13-03-2020
How to Cite
[1]
de Abreu Costa , P.C. et al. 2020. Failure mode and effect analysis in the preparation and dispensation of chemotherapy. Global Nursing. 19, 2 (Mar. 2020), 68–108. DOI:https://doi.org/10.6018/eglobal.389551.
Issue
Section
ORIGINAL RESEARCH