Applying HFMEA to Prevent Chemotherapy Errors

Cheng, Chia-Hui; Chou, Chia-Jen; Wang, Pa‐Chun; Lin, Hsi-Yen; Kao, Chi-Lan; Su, Chao‐Ton

doi:10.1007/s10916-010-9616-7

Cited by 54 publications

(64 citation statements)

References 18 publications

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“…The process differs from commonly utilized retrospective improvement methodologies, such as root cause analysis, which is used to investigate safety events after they occur (13)(14)(15). This methodology has been successfully applied in other health care arenas (16,17), but there is limited description of its use in evaluating anesthesia processes (18).…”

Section: Introductionmentioning

confidence: 99%

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Martin

Grigg

Verma

et al. 2017

Pediatric Anesthesia

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SummaryThe Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.

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Section: Introductionmentioning

confidence: 99%

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Martin

Grigg

Verma

et al. 2017

Pediatric Anesthesia

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“…Computerized physician order entry (cpoe) has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors [1][2][3][4][5][6][7] . Since the early 2000s, research has established a knowledge base for successful cpoe implementation and ongoing use.…”

Section: Introductionmentioning

confidence: 99%

Toward Successful Migration to Computerized Physician Order Entry for Chemotherapy

et al. 2014

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advancing successful adoption of cpoe for chemotherapy were identified:• The need to investigate variances in workflows and practices in chemotherapy ordering and administration • The need to develop best-practice cpoe procurement and implementation guidance specifically for chemotherapy • The need to measure the effects of cpoe implementation in medical oncology ConclusionsAddressing the existing challenges in cpoe usability and adoption for chemotherapy, and accelerating successful migration to cpoe by cancer care providers requires future research focusing on workflow variations, chemotherapy-specific cpoe procurement needs, and implementation guidance needs.

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“…Recommendations like CPOE may improve safety related to the use of standardized templates, as well as the opportunity to imbed alerts when deviations from the guidelines occur (Bonnabry et al, 2006; Cheng et al, 2012; Kullberg et al, 2013). However, the sophistication of such a system is largely dependent on the extent to which it is maintained and updated.…”

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confidence: 99%

Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses

Baldwin¹,

Rodríguez²

2016

CJON

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Background The prevalence of medication errors associated with chemotherapy administration is not precisely known. Little evidence exists concerning the extent or nature of errors; however, some evidence demonstrates that errors are related to prescribing. This article demonstrates how the review of chemotherapy orders by a designated nurse known as a verification nurse (VN) at a National Cancer Institute–designated comprehensive cancer center helps to identify prescribing errors that may prevent chemotherapy administration mistakes and improve patient safety in outpatient infusion units. Objectives This article will describe the role of the VN and details of the verification process. Methods To identify benefits of the VN role, a retrospective review and analysis of chemotherapy near-miss events from 2009–2014 was performed. Findings A total of 4,282 events related to chemotherapy were entered into the Reporting to Improve Safety and Quality system. A majority of the events were categorized as near-miss events, or those that, because of chance, did not result in patient injury, and were identified at the point of prescribing.

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Applying HFMEA to Prevent Chemotherapy Errors

Cited by 54 publications

References 18 publications

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Toward Successful Migration to Computerized Physician Order Entry for Chemotherapy

Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses

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