Failure Mode, Effects and Criticality Analysis on Cytotoxic Drug Safety Management in Pharmacy Intravenous Admixture Services

Ma Shuangshuang; Cai Lun; Shen Wei

doi:10.13407/j.cnki.jpp.1672-108X.2023.08.008

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Failure Mode, Effects and Criticality Analysis on Cytotoxic Drug Safety Management in Pharmacy Intravenous Admixture Services

更新时间：2023-08-23

- Failure Mode, Effects and Criticality Analysis on Cytotoxic Drug Safety Management in Pharmacy Intravenous Admixture Services
- Vol. 29, Issue 8, Pages: 28-30(2023)
- 作者机构：
  
  南京医科大学附属宿迁第一人民医院,江苏,宿迁,223800
- 作者简介：
- 基金信息：
- DOI：10.13407/j.cnki.jpp.1672-108X.2023.08.008
  CLC：
- Published：2023，
  
  Published Online：10 August 2023，
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Ma Shuangshuang, Cai Lun, Shen Wei. Failure Mode, Effects and Criticality Analysis on Cytotoxic Drug Safety Management in Pharmacy Intravenous Admixture Services. [J]. 29(8):28-30(2023)
DOI：

Ma Shuangshuang, Cai Lun, Shen Wei. Failure Mode, Effects and Criticality Analysis on Cytotoxic Drug Safety Management in Pharmacy Intravenous Admixture Services. [J]. 29(8):28-30(2023) DOI： 10.13407/j.cnki.jpp.1672-108X.2023.08.008.

摘要

目的:降低静脉用药调配中心(PIVAS)细胞毒药物调配过程中的差错和溢出风险。方法:利用失效模式与效应危害分析(FMECA)对南京医科大学附属宿迁第一人民医院 PIVAS 细胞毒药物在药品领用、医嘱审核、贴签摆药、药品配制、成品核对和分拣外送等流程中的失效模式进行分析并评估其危害等级。通过比较改进措施实施前后风险优先值(RPN)和差错事件评价整改效果。结果:找出 15 个高等和中等危害等级的失效模式

并积极实施改进措施。改进措施实施后 15 项失效模式 RPN 平均降幅 54. 4%

差错事件发生率明显降。结论:运用 FMECA 对细胞毒药物调配各环节进行风险防范管理

可有效减少细胞毒药物调配差错

保障患者和医护人员安全。

Abstract

Objective: To reduce the errors and overflow risks in the preparation of cytotoxic drugs in pharmacy intravenous admixture services (PIVAS). Methods: Failure mode

effects and criticality analysis (FMECA) was used in the preparation of cytotoxic drugs including drug requisition

medical order review

labeling and drug placement

dosing

finished infusion checking and sorting out

failure modes and hazard ratings were evaluated. Effect of the rectification was evaluated by comparing the risk priority value (RPN) and error events before and after the implementation of FMECA. Results: Totally 15 failure modes with high and medium hazard rating were identified and active measures were implemented. After the implementation of FMECA

RPN was reduced by 54. 4%

as well as error events were significantly reduced. Conclusion: The use of FMECA for risk prevention management in the preparation of cytotoxic drugs can effectively reduce error events and ensure the safety of patients and medical staff.

关键词

失效模式与效应危害分析细胞毒药物静脉用药调配中心调配差错溢出

Keywords

failure mode effects and criticality analysiscytotoxic drugspharmacy intravenous admixture servicesspensing errorsoverflow

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