Aranaz-Andrés Jesús María, Bermejo-Vicedo Teresa, Muñoz-Ojeda Isabel, Delgado-Silveira Eva, Chamorro-Rubio Sonia, Fernández-Puentes Ángeles, García-Collía Marta, Guerra-Alia Eva María
Servicio de Medicina Preventiva, Hospital Ramón y Cajal, Madrid.
Servicio de Farmacia, Hospital Ramón y Cajal, Madrid..
Farm Hosp. 2017 Nov 1;41(6):674-677. doi: 10.7399/fh.10792.
To carry out a Failure Mode and Effects Analysis (FMEA) to the use of oral syringes.
A multidisciplinary team was assembled within the Safety Committee. The stages of oral administration process of liquid medication were analysed, identifying the most critical and establishing the potential modes of failure that can cause errors. The impact associated with each mode of failure was calculated using the Risk Priority Number (RPN). Preventive actions were proposed.
Five failure modes were identified, all classified as high risk (RPN> 100). Seven of the eight preventive actions were implemented.
The FMEA methodology was a useful tool. It has allowed to know the risks, analyse the causes that cause them, their effects on patient safety and the measures to reduce them.
对口服注射器的使用进行失效模式与效应分析（FMEA）。
在安全委员会内组建了一个多学科团队。分析了液体药物口服给药过程的各个阶段，确定了最关键的环节，并确定了可能导致差错的潜在失效模式。使用风险优先数（RPN）计算与每种失效模式相关的影响。提出了预防措施。
确定了五种失效模式，均被归类为高风险（RPN>100）。八项预防措施中的七项得到了实施。
FMEA方法是一种有用的工具。它有助于了解风险，分析导致风险的原因、其对患者安全的影响以及降低风险的措施。
