Application of Failure Mode and Effect Analysis to reduce errors in medication administration in pediatric intensive care units: A quality improvement report

Abstract

Background: prevention of medication errors in pediatric intensive care due to age and physiological condition of the patient it is very important .This study aims to identify, evaluate, and analyze potential errors in the process of drug prescription and administration in pediatric intensive care unit of Imam Reza teaching hospital in Mashhad using systematic approach of FMEA. Methods: In this mixed method descriptive cross-sectional study, modes and effects of error were identified and analyzed using FMEA. This study was conducted in 10 steps. To determine potential failure modes and effects of errors team brainstorming tool is used and Factors affecting modes of error were identified using cause and effect graph (fishbone) and brainstorming method. Determined improvement strategies through interviews with team members and taking into account the requirements of the proposed risk priority number again for each of interventions were calculated. Results: Identification of drug prescription and administration in intensive care unit resulted in identifying seven activities and 29 sub-processes in total drug prescription and administration processes. 68 error modes were identified of these 27 were detected as hight risk failure mode (40 ≤ RPN). Interventions that were designed to correct these errors reduced the amount of up to 50%. conclusion: FMEA showed high potentials in identifying, evaluating, prioritizing and analyzing errors in drug prescription and administration processes in pediatric intensive care unit.