Khani-Jazani Reza, Molavi-Taleghani Yasamin, Seyedin Hesam, Vafaee-Najar Ali, Ebrahimipour Hossein, Pourtaleb Arefeh
Department of Ergonomics, Faculty of Health, Safety and Environment, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Student Research Committee, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran.
Iran J Pharm Res. 2015 Spring;14(2):495-504.
Evaluation and improvement of drug management process are essential for patient safety. The present study was performed whit the aim of assessing risk of drug management process in Women Surgery Department of QEH using HFMEA method in 2013. A mixed method was used to analyze failure modes and their effects with HFMEA. To classify failure modes; nursing errors in clinical management model, for classifying factors affecting error; approved model by the UK National Health System, and for determining solutions for improvement; Theory of Inventive Problem Solving, were used. 48 failure modes were identified for 14 sub-process of five steps drug management process. The frequency of failure modes were as follow :35.3% in supplying step, 20.75% in prescription step, 10.4% in preparing step, 22.9% in distribution step and 10.35% in follow up and monitoring step. Seventeen failure modes (35.14%) were considered as non-acceptable risk (hazard score≥ 8) and were transferred to decision tree. Among 51 Influencing factors, the most common reasons for error were related to environmental factors (21.5%), and the less common reasons for error were related to patient factors (4.3%). HFMEA is a useful tool to evaluating, prioritization and analyzing failure modes in drug management process. Revision drug management process based focus-PDCA, assessing adverse drug reactions (ADR), USE patient identification bracelet, holding periodical pharmaceutical conferences to improve personnel knowledge, patient contribution in drug therapy; are performance solutions which were placed in work order.
评估和改进药物管理流程对患者安全至关重要。本研究于2013年采用失效模式与效应分析（HFMEA）方法，旨在评估QEH妇女外科药物管理流程的风险。采用混合方法，运用HFMEA分析失效模式及其影响。为对失效模式进行分类，采用临床管理模式中的护理差错；为对影响差错的因素进行分类，采用英国国家医疗服务体系认可的模式；为确定改进方案，采用发明问题解决理论。在五步药物管理流程的14个子流程中识别出48种失效模式。失效模式的发生率如下：供应环节为35.3%，处方环节为20.75%，调配环节为10.4%，发放环节为22.9%，随访与监测环节为10.35%。17种失效模式（35.14%）被视为不可接受风险（危害评分≥8）并转入决策树。在51个影响因素中，最常见的差错原因与环境因素有关（21.5%），最不常见的差错原因与患者因素有关（4.3%）。HFMEA是评估、确定药物管理流程失效模式优先级和分析失效模式的有用工具。基于重点-计划-执行-检查-处理（PDCA）修订药物管理流程、评估药物不良反应（ADR）、使用患者识别手环、定期召开药学会议以提高人员知识、让患者参与药物治疗；这些都是已列入工作顺序的绩效改进方案。
