Failure-mode and effects analysis in improving a drug distribution system.

摘要: The medication error rate in an existing ward stock drug distribution system and alternative developed after failure-mode effects analysis (FMEA) was applied to the studied. In of a large teaching hospital Western Australia, bulk packs were stored cupboards on wards, products transferred trolleys before dose administration by nurses. A pharmacist used disguised-observer technique determine for medical surgical ward. errors each step studied FMEA. unit supply individual-patient dispensing (USIPD) formulated respond failure modes identified. this system, five-day dispensed patient from satellite pharmacy close Medication charts reviewed pharmacist, drugs labeled vials that placed locked drawer at patient's bedside. under USIPD determined. Problem areas identified FMEA included availability, review orders, selection, patient-related issues, use nurses' time. percentage opportunities during which any occurred significantly lower both wards. identify deficiencies led Australian hospital. An designed address problems associated with fewer errors.