투약오류 예방 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 enter more precise order entry, and the Pharmacy Drug Master (PDM) was modified to decrease preventable error. To prevent mistakes from occurring for verbal chemotherapy nurse orders, a new computer entry system was created. The ward number was placed uniformly on the same parts of inpatient drug labels, and made more recognizable. More information was printed on the repackaged drugs for pharmacists and nurses to use. The purpose of the study was to decrease the number of the reported medication error adverse effect by 10%. At the end of the study, 17 medication error adverse effect reports were recorded, which is a 19% decrease from 21 reports in the first investigation. The Medication Error Criticality Index decreased from 10,034 points to 5,812 points showing a 42.1% decrease.

Conclusion: A greater reduction of percentage was shown in some processes, but some process did not show any changes. RPNs tied to human resources showed less reduction, compared to other processes. The common denominator among physicians, pharmacists, and nurses is inaccurate communication. Systemic regular training should be required for physicians, pharmacists, and nurses to minimize preventable medication error and develop accurate communication skill.