Skip to main content
Erschienen in: Journal of Medical Systems 3/2012

01.06.2012 | ORIGINAL PAPER

Applying HFMEA to Prevent Chemotherapy Errors

verfasst von: Chia-Hui Cheng, Chia-Jen Chou, Pa-Chun Wang, Hsi-Yen Lin, Chi-Lan Kao, Chao-Ton Su

Erschienen in: Journal of Medical Systems | Ausgabe 3/2012

Einloggen, um Zugang zu erhalten

Abstract

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.
Literatur
1.
Zurück zum Zitat Dizon, D. S., Sabbatini, P. J., Aghajanian, C., Hensley, M. L., and Spriggs, D. R., Analysis of patients with epithelial ovarian cancer of fallopian tube carcinoma retreated with cisplatin after development of a carboplatin allergy. Gynecol. Oncol. 82:378–82, 2002.CrossRef Dizon, D. S., Sabbatini, P. J., Aghajanian, C., Hensley, M. L., and Spriggs, D. R., Analysis of patients with epithelial ovarian cancer of fallopian tube carcinoma retreated with cisplatin after development of a carboplatin allergy. Gynecol. Oncol. 82:378–82, 2002.CrossRef
2.
Zurück zum Zitat Sheridan-Leos, N., Schulmeister, L., and Hartranft, S., Failure mode and effect analysis: a technique to prevent chemotherapy errors. Clin. J. Oncol. Nurs. 10:393–398, 2006.CrossRef Sheridan-Leos, N., Schulmeister, L., and Hartranft, S., Failure mode and effect analysis: a technique to prevent chemotherapy errors. Clin. J. Oncol. Nurs. 10:393–398, 2006.CrossRef
3.
Zurück zum Zitat Schulmeister, L., Chemotherapy medication errors: description, severity, and contributing factors. Oncol. Nurs. Forum 26:1033–1042, 1999. Schulmeister, L., Chemotherapy medication errors: description, severity, and contributing factors. Oncol. Nurs. Forum 26:1033–1042, 1999.
4.
Zurück zum Zitat Greenall, J., Failure modes and effects analysis: a tool for identifying risk in community pharmacies. Can. Pharm. J. 140:191–193, 2007. Greenall, J., Failure modes and effects analysis: a tool for identifying risk in community pharmacies. Can. Pharm. J. 140:191–193, 2007.
5.
Zurück zum Zitat Roland, H. E., and Moriarity, B., System safety engineering and management. Wiley, Hoboken, 1990.CrossRef Roland, H. E., and Moriarity, B., System safety engineering and management. Wiley, Hoboken, 1990.CrossRef
6.
Zurück zum Zitat Teoh, P. C., and Case, K., An evaluation of failure modes and effect analysis generating method for conceptual design. Int. J. Comput. Integr. Manuf. 18:279–293, 2005.CrossRef Teoh, P. C., and Case, K., An evaluation of failure modes and effect analysis generating method for conceptual design. Int. J. Comput. Integr. Manuf. 18:279–293, 2005.CrossRef
7.
Zurück zum Zitat Joint Commission on Accreditation on Healthcare Organization, Revisions to Joint Commission standards in support of patient safety and medical/health care error reduction. Joint Commission on Accreditation on Healthcare Organization, Oakbrook Terrace, 2002. Joint Commission on Accreditation on Healthcare Organization, Revisions to Joint Commission standards in support of patient safety and medical/health care error reduction. Joint Commission on Accreditation on Healthcare Organization, Oakbrook Terrace, 2002.
8.
Zurück zum Zitat Hambleton, M., Applying root cause analysis and failure mode and effect analysis to our compliance programs. J. Health Care Compl. 7:5–13, 2005. Hambleton, M., Applying root cause analysis and failure mode and effect analysis to our compliance programs. J. Health Care Compl. 7:5–13, 2005.
9.
Zurück zum Zitat Kunac, D. L., and Reith, D. M., Identification of priority for medication safety in neonatal intensive care. Drug Saf. 28:251–261, 2005.CrossRef Kunac, D. L., and Reith, D. M., Identification of priority for medication safety in neonatal intensive care. Drug Saf. 28:251–261, 2005.CrossRef
10.
Zurück zum Zitat Voeffray, M., Pannatier, A., Stupp, R., Fucina, N., Leyvraz, S., and Wasserfallen, J. B., Effect of computerisation on the quality and safety of chemotherapy prescription. Qual. Saf. Health Care 15:418–421, 2006.CrossRef Voeffray, M., Pannatier, A., Stupp, R., Fucina, N., Leyvraz, S., and Wasserfallen, J. B., Effect of computerisation on the quality and safety of chemotherapy prescription. Qual. Saf. Health Care 15:418–421, 2006.CrossRef
11.
Zurück zum Zitat Markert, A., Thierry, V., Kleber, M., et al., Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment. Int. J. Cancer 124:722–820, 2009.CrossRef Markert, A., Thierry, V., Kleber, M., et al., Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment. Int. J. Cancer 124:722–820, 2009.CrossRef
12.
Zurück zum Zitat Bonnabry, P., Cingria, L., Ackermann, M., Behrens, M., and Engelhardt, M., Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int. J. Qual. Health Care 18:9–16, 2006.CrossRef Bonnabry, P., Cingria, L., Ackermann, M., Behrens, M., and Engelhardt, M., Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int. J. Qual. Health Care 18:9–16, 2006.CrossRef
13.
Zurück zum Zitat American Society of Health-System Pharmacists, ASHP guidelines on preventing medication errors with antineoplastic agents. Am. J. Health Syst. Pharm. 59:1648–1668, 2002. American Society of Health-System Pharmacists, ASHP guidelines on preventing medication errors with antineoplastic agents. Am. J. Health Syst. Pharm. 59:1648–1668, 2002.
14.
Zurück zum Zitat DeRosier, J., Stalhandske, E., Bagian, J. P., and Nudell, T., Using health care failure mode and effect analysis: the VA national center for patient safety’s prospective risk analysis system. Jt. Comm. J. Qual. Improv. 28:248–267, 2002. DeRosier, J., Stalhandske, E., Bagian, J. P., and Nudell, T., Using health care failure mode and effect analysis: the VA national center for patient safety’s prospective risk analysis system. Jt. Comm. J. Qual. Improv. 28:248–267, 2002.
15.
Zurück zum Zitat Habraken, M. M., Van der Schaaf, T. W., Leistikow, I. P., et al., Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch health care. Ergonomics 52:809–819, 2009.CrossRef Habraken, M. M., Van der Schaaf, T. W., Leistikow, I. P., et al., Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch health care. Ergonomics 52:809–819, 2009.CrossRef
16.
Zurück zum Zitat Kimehi-Woods, J., Shultz, J. P., Leistikow, I. P., and Reijnders-Thijssen, P. M., Using HFMEA to assess potential for patient harm from tubing misconnections. Jt. Comm. J. Qual. Patient Saf. 32:373–381, 2006. Kimehi-Woods, J., Shultz, J. P., Leistikow, I. P., and Reijnders-Thijssen, P. M., Using HFMEA to assess potential for patient harm from tubing misconnections. Jt. Comm. J. Qual. Patient Saf. 32:373–381, 2006.
17.
Zurück zum Zitat van Tilburg, C. M., Leistikow, I. P., Rademaker, C. M., Bierings, M. B., and van Dijk, A. T., Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward. Qual. Saf. Health Care 15:58–63, 2006.CrossRef van Tilburg, C. M., Leistikow, I. P., Rademaker, C. M., Bierings, M. B., and van Dijk, A. T., Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward. Qual. Saf. Health Care 15:58–63, 2006.CrossRef
18.
Zurück zum Zitat Esmail, R., Cummings, C., Dersch, D., Duchscherer, G., Glowa, J., and Liggett, G., Patient safety and adverse events team. Using health care failure mode and effect analysis tool to review the process of ordering and administrating potassium chloride and potassium phosphate. Healthc. Q. 8:73–80, 2005. Esmail, R., Cummings, C., Dersch, D., Duchscherer, G., Glowa, J., and Liggett, G., Patient safety and adverse events team. Using health care failure mode and effect analysis tool to review the process of ordering and administrating potassium chloride and potassium phosphate. Healthc. Q. 8:73–80, 2005.
19.
Zurück zum Zitat Linkin, D. R., Sausman, C., Santos, L., Lyons, C., Fox, C., and Aumiller, L., Applicability of health care failure mode and effect analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments. Clin. Infect. Dis. 41:1014–1019, 2005.CrossRef Linkin, D. R., Sausman, C., Santos, L., Lyons, C., Fox, C., and Aumiller, L., Applicability of health care failure mode and effect analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments. Clin. Infect. Dis. 41:1014–1019, 2005.CrossRef
20.
Zurück zum Zitat Cohen, M. R., Anderson, R. W., Attilio, R. M., Green, L., Muller, R. J., and Pruemer, J. M., Preventing medication errors in cancer chemotherapy. Am. J. Health Syst. Pharm. 53:737–746, 1996. Cohen, M. R., Anderson, R. W., Attilio, R. M., Green, L., Muller, R. J., and Pruemer, J. M., Preventing medication errors in cancer chemotherapy. Am. J. Health Syst. Pharm. 53:737–746, 1996.
21.
Zurück zum Zitat Kim, G. R., Chen, A. R., Arceci, R. J., Mitchell, S. H., Kokoszka, K. M., and Daniel, D., Error reduction in pediatric chemotherapy computerized order entry and failure modes and effects analysis. Arch. Pediatr. Adolesc. Med. 160:495–498, 2006.CrossRef Kim, G. R., Chen, A. R., Arceci, R. J., Mitchell, S. H., Kokoszka, K. M., and Daniel, D., Error reduction in pediatric chemotherapy computerized order entry and failure modes and effects analysis. Arch. Pediatr. Adolesc. Med. 160:495–498, 2006.CrossRef
Metadaten
Titel
Applying HFMEA to Prevent Chemotherapy Errors
verfasst von
Chia-Hui Cheng
Chia-Jen Chou
Pa-Chun Wang
Hsi-Yen Lin
Chi-Lan Kao
Chao-Ton Su
Publikationsdatum
01.06.2012
Verlag
Springer US
Erschienen in
Journal of Medical Systems / Ausgabe 3/2012
Print ISSN: 0148-5598
Elektronische ISSN: 1573-689X
DOI
https://doi.org/10.1007/s10916-010-9616-7

Weitere Artikel der Ausgabe 3/2012

Journal of Medical Systems 3/2012 Zur Ausgabe