Prevention of Medication Error by Failure Mode and Effects Analysis

Abstract

Background : Medication errors can cause delayed hospital days, increased health costs, and mortality for patients. According to the Korea Patient Safety reporting & learning system (KOPS) in Korea in 2019, 3,798 of 11,953 patient safety reports were related to medication error which are 31.8% of the total reports. Methods :Team compromising of physicians, nurses, pharmacists, etc, used the Fish Bone Diagram to identify the root cause. The pay-off matrix was used to rank prioritizing strategy with less effort with greater improvement effect. The program was restructured into a lower risk program and the new program was analyzed and reviewed by the team. Results :The Computerized Provider Order Entry (CPOE) was modified, so physicians can en-