gms | German Medical Science

25. Jahrestagung der Gesellschaft für Arzneimittelanwendungsforschung und Arzneimittelepidemiologie (GAA)

Gesellschaft für Arzneimittelanwendungsforschung und Arzneimittelepidemiologie

22.11. - 23.11.2018, Bonn/Bad Godesberg

Using failure mode and effects analysis to increase patients’ safety in chemotherapy

Meeting Abstract

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  • corresponding author presenting/speaker Lisa Weber - Apotheke des Universitätsklinikums Bonn, Bonn, Germany
  • author Ingo Schulze - Apotheke des Universitätsklinikums Bonn, Bonn, Germany
  • author Ulrich Jaehde - Pharmazeutisches Institut, Klinische Pharmazie, Universität Bonn, Bonn, Germany

Gesellschaft für Arzneimittelanwendungsforschung und Arzneimittelepidemiologie e.V. (GAA). 25. Jahrestagung der Gesellschaft für Arzneimittelanwendungsforschung und Arzneimittelepidemiologie. Bonn/Bad Godesberg, 22.-23.11.2018. Düsseldorf: German Medical Science GMS Publishing House; 2018. Doc18gaa18

doi: 10.3205/18gaa18, urn:nbn:de:0183-18gaa186

Veröffentlicht: 23. November 2018

© 2018 Weber et al.
Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). Lizenz-Angaben siehe http://creativecommons.org/licenses/by/4.0/.


Gliederung

Text

Background: Ensuring the safety of patients in high-risk processes, e.g., chemotherapy, is a challenging task. Medication errors may occur during chemotherapy and could have fatal consequences. Healthcare Failure Mode and Effects Analysis (FMEA) is a method used to detect potential risks and prevent them before they can occur. This prospective, multidisciplinary team-based analysis offers also the possibility to check the interdisciplinary collaboration between physicians, pharmacists, and nurses, which could also pose a risk for system failures. The goal of this study was to evaluate the medication process of intravenous tumor therapy from prescription to administration in order to guarantee a high standard of patient safety.

Materials and methods: The study was performed at the University Hospital of Bonn, Germany, from December 2016 to June 2017. After assembling a multidisciplinary team consisting of oncologists, oncological pharmacists, pharmacy technicians, oncological nurses, and employees of risk management, the individual steps of prescription, compounding, transport and administration of chemotherapy were mapped in a flow-diagram. The possible failures were identified and analyzed by calculating the risk priority numbers (RPNs) on the basis of the likelihood of occurrence, severity, and detectability. Finally, corrective actions were developed and after hypothetical implementation re-analyzed to measure their effects on the process.

Results: The team identified a total of fifty-two potential failure modes. Relating to the RPNs the most critically steps in the process were associated with the prescription, namely,

  • incorrect information of individual parameters of the patient (e.g., weight, body surface area),
  • non-standardized chemotherapy protocols, and
  • problems related to the supportive therapy (non-adherence, ignorance of necessity).

A significant risk reduction for most of the failure modes was assessed by implementing suitable corrective actions.

Conclusion: The implementation of this analysis has not only identified various safety gaps, but also shows how patient safety during chemotherapy can be enhanced. Moreover, it has sensitized the practitioners to failure modes that could occur in their work routine.


References

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Cheng CH, Chou CJ, Wang PC, Lin HY, Kao CL, Su CT. Applying HFMEA to prevent chemotherapy errors. J Med Syst. 2012 Jun;36(3):1543-51. DOI: 10.1007/s10916-010-9616-7 Externer Link
2.
Stojkovic T, Marinkovic V, Jaehde U, Manser T. Using Failure mode and Effects Analysis to reduce patient safety risks related to the dispensing process in the community pharmacy setting. Res Social Adm Pharm. 2017 Nov;13(6):1159-1166. DOI: 10.1016/j.sapharm.2016.11.009 Externer Link