Failure Mode and Effects Analysis for safety in preparation and dispensing chemotherapeutic drugs
Failure Mode and Effects Analysis, Patient Safety, Medication Errors, Drug Therapy.
INTRODUCTION: Chemotherapeutic drugs are medicines that require high-risk initiatives to prevent failures in care that cause unnecessary damage to patients. OBJECTIVE: Perform a Failure Mode and Effects Analysis (FMEA) to prospectively identify the risks related to the phase of the preparation and dispensing of chemotherapeutic drugs in a hospital. METHOD: This is a descriptive study performed in an outpatient unit of a reference center in Oncology, philanthropist, from the city of Natal-RN. For the application of the tool is composed of a multidisciplinary team consisting of a mediator, pharmacists, nurse specialist and nursing technician involved in the process. The steps for preparing and dispensing chemotherapeutic drugs were described graphically by means of a simple flowchart. Then were listed the possible failures of each subprocess using Rain of ideas. Each failure was assessed using the array of risk score. According to the score obtained was used a decision tree to detect which flaws needed interventions. From the results obtained were proposed interventions and monitoring indicators. RESULTS: 17 failure modes were identified in steps of preparation and dispensation of chemotherapeutic drugs. Among the 17 failure modes, three obtained value > 8 and were therefore analyzed with decision tree for HFMEA. The failure mode "to change the output window of the Medicine" potential causes: lack of attention, lack of signs in the window and lack of knowledge of the process. The failure mode "wrong Calculation of the dose of intrathecal drug" had as potential causes: defective calculator, change in presentation of the medicinal product and work overload. The following interventions have been proposed: stipulate limits of meds to be handled at a time, the Windows flag internally and externally, containing work instructions and perform the check calculation of double medicine intrathecal and record in own printed. CONCLUSION: The FMEA tool proved to be a valid method to improve patient safety, as it allows a prospective analysis in the process of chemotherapy medication preparation and dispensing phase, with the objective of identifying potential failures and their associated causes, and formulate strategies for fixing such vulnerabilities.