Applying HFMEA to Prevent Chemotherapy Errors

被引:72
作者
Cheng, Chia-Hui [2 ]
Chou, Chia-Jen [1 ]
Wang, Pa-Chun [3 ,4 ,5 ]
Lin, Hsi-Yen [6 ]
Kao, Chi-Lan [6 ]
Su, Chao-Ton [1 ]
机构
[1] Natl Tsing Hua Univ, Dept Ind Engn & Engn Management, Hsinchu 300, Taiwan
[2] Cathay Gen Hosp, Qual Management Ctr, Taipei, Taiwan
[3] Cathay Gen Hosp, Dept Otolaryngol, Taipei, Taiwan
[4] Fu Jen Catholic Univ, Sch Med, Taipei Cty, Taiwan
[5] China Med Univ, Dept Publ Hlth, Coll Publ Hlth, Taichung, Taiwan
[6] Cathay Gen Hosp, Dept Pharm, Taipei, Taiwan
关键词
Healthcare failure mode and effect analysis (HFMEA); Chemotherapy process; Risk analysis; Computerized physician order entry; PROSPECTIVE RISK ANALYSIS; CARE FAILURE MODE; HEALTH-CARE; CANCER-CHEMOTHERAPY; MEDICATION ERRORS; SAFETY;
D O I
10.1007/s10916-010-9616-7
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
To evaluate risk and vulnerability in the chemotherapy process using a proactive risk analysis method. Healthcare failure mode and effect analysis (HFMEA) was adopted to identify potential chemotherapy process failures. A multidisciplinary team is formed to identify, evaluate, and prioritize potential failure modes based on a chemotherapy process flowchart. Subsequently, a decision tree is used to locate potential failure modes requiring urgent improvement. Finally, some recommended actions are generated and executed to eliminate possible risks. A total of 11 failure modes were identified with high hazard scores in both inpatient and outpatient processes. Computerized physician order entry was adopted to eliminate potential risks in chemotherapy processes. Chemotherapy prescription errors significantly decreased from 3.34% to 0.40%. Chemotherapy is regarded as a high-risk process. Multiple errors can occur during ordering, preparing, compounding, dispensing, and administering medications. Subsequently, these can lead to serious consequences. HFMEA is a useful tool to evaluate potential risk in healthcare processes.
引用
收藏
页码:1543 / 1551
页数:9
相关论文
共 21 条
[1]   Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process [J].
Bonnabry, P ;
Cingria, L ;
Ackermann, M ;
Sadeghipour, F ;
Bigler, L ;
Mach, N .
INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE, 2006, 18 (01) :9-16
[2]   Preventing medication errors in cancer chemotherapy [J].
Cohen, MR ;
Anderson, RW ;
Attilio, RM ;
Green, L ;
Muller, RJ ;
Pruemer, JM .
AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY, 1996, 53 (07) :737-746
[3]  
DeRosier Joseph, 2002, Jt Comm J Qual Improv, V28, P248
[4]   Analysis of patients with epithelial ovarian cancer or fallopian tube carcinoma retreated with cisplatin after the development of a carboplatin allergy [J].
Dizon, DS ;
Sabbatini, PJ ;
Aghajanian, C ;
Hensley, ML ;
Spriggs, DR .
GYNECOLOGIC ONCOLOGY, 2002, 84 (03) :378-382
[5]  
Esmail Rosmin, 2005, Healthc Q, V8 Spec No, P73
[6]  
Greenall J., 2007, CAN PHARM J, V140, No, P191
[7]   Prospective risk analysis of health care processes: A systematic evaluation of the use of HFMEA™ in Dutch health care [J].
Habraken, M. M. P. ;
Van der Schaaf, T. W. ;
Leistikow, I. P. ;
Reijnders-Thijssen, P. M. J. .
ERGONOMICS, 2009, 52 (07) :809-819
[8]  
Hambleton M., 2005, J HLTH CARE COMPLIAN, V7, P5
[9]   Error reduction in pediatric chemotherapy - Computerized order entry and failure modes and effects analysis [J].
Kim, GR ;
Chen, AR ;
Arceci, RJ ;
Mitchell, SH ;
Kokoszka, KM ;
Daniel, D ;
Lehmann, CU .
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE, 2006, 160 (05) :495-498
[10]  
Kimchi-Woods J, 2006, JT COMM J QUAL PATIE, V32, P373