514 oral ORION(r): SIMPLE AND EFFECTIVE METHOD FOR SYSTEMIC ANALYSIS OF EVENT OCCURRING IN HOSPITAL PRACTICE

An Experience Feedback Committee for Improving Medication Process Safety: An Observational Study in a Hospital Pharmacy Department

“…This included a median of 3 pharmacists [IQR, [3][4] for a median of 1.5 technicians [IQR, 1-2] per meeting. A total of 320 events concerning the pharmacy activities were examined by the EFC with a median of 13 events [IQR, [8][9][10][11][12][13][14][15][16][17][18] per meeting.…”

“…The pharmacy department EFC was set up in March 2008 and worked through a written procedure in accordance with the method proposed by Air France Consulting [2,3]. The committee was composed of volunteer representatives of various professions within the pharmacy department and met once a month.…”

“…Each investigation was carried out during the month following the EFC meeting by a designated person. The person in charge of the investigation performed the analysis using the ORION© method developed by Air France Consulting [3]. The main steps of the method were: collecting data; describing the chronological facts that occurred before, during and after the event; describing the failures; looking for causes of errors and latent factors that could have contributed to failures; setting up corrective actions; and writing a report of the analysis.…”

“…Originating from civil aviation security systems, the method has been adapted to healthcare facilities and successfully implemented in radiotherapy units by the company Air France Consulting [3]. An EFC is a multidisciplinary team representing the diversity of the functions encountered in the medical entity.…”

“…They choose priority incidents that need to be analysed and propose corrective actions. The main principles of this method are that patient safety must be managed within a medical team, the team must also consider the near-miss events and the actions must concern latent factors that contributed to the occurrence of the near-miss event [3].…”