scholarly journals Observational Study of Medication Error in Outpatient Pharmacy RSUP Dr. Hasan Sadikin Bandung

2017 ◽  
Vol 15 (2) ◽  
pp. 210
Author(s):  
Viki Hestiarini ◽  
Lia Amalia ◽  
Eni Margayani
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Drug Information ◽  
Data Entry ◽  
Care Process ◽  
Analysis Method ◽  
Risk Priority Number ◽  
Effect Analysis ◽  
Root Cause ◽  
Cause Of Failure

Medication error can occur at all stages, starting from prescribing, dispensing and administration of drugs. This study aims to assess the medication errors that occur in the pharmaceutical care process and analyze the cause of failure using the root cause analysis method, to improvement action and decrease the incidence of medication errors. The data were completeness prescription, frequency of dispensing error and completeness of drug information. The number of sample was 1100 prescriptions Prescribing errors were found the potential injury 15.69±11.51% and near missed error 0.5±0.55%. At dispensing stage, occur 427 incidences (9.71%), consist of two incidences (0.04%) for validation assessment regulations, 224 incidences (5.09%) of data entry, 113 incidences (2.57%) of retrieval of drugs, 19 incidences (0.43%) of fi ll in drugs, 69 incidences (1.57%) of fi nal check. At dispensing stage, near missed 330 incidences (7.51%) of near missed and 97 incidences (2.21%) of potential injury. Failure mode and effect analysis calculate of risk priority number, the drug retrieval (RPN 210) and data entry (RPN 126) were analyzed root cause of the analysis for man, material, method, facility and environment.

scholarly journals To err is human: medication patient safety in aged care, a case study

2018 ◽  
Vol 19 (2) ◽  
pp. 126-134
Author(s):  
Julia Gilbert ◽  
Jeong-ah Kim
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Management ◽  
Care Facility ◽  
Root Cause Analysis ◽  
Aged Care ◽  
Cause Analysis ◽  
Content Type ◽  
Root Cause

Purpose The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study. Design/methodology/approach In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility. Findings Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013). Originality/value Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

scholarly journals Risk Analysis in the Automotive Industry

2020 ◽  
Author(s):  
Annamária Koncz ◽  
László Pokorádi ◽  
Zsolt Csaba Johanyák
Keyword(s):  
Risk Analysis ◽  
Failure Mode ◽  
Automotive Industry ◽  
Root Cause Analysis ◽  
Automotive Sector ◽  
Analysis Method ◽  
Effect Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Safety And Reliability

The automotive industry is one of the most dynamically growing fields of the manufacturingarea. Besides this, it has very strict rules concerning safety and reliability. In our work, our aim is to point out the importance of the automotive industry (based on statistics) and the rules in connection with risk and root cause analysis. The most important risk analysis method is the Failure Mode and Effect Analysis (FMEA). According to standards and OEM regulations, FMEA is obligatory in the automotive sector. In our study, we summarise the area of FMEA usage, its types and process steps.

scholarly journals Reliability analysis of hanger shot blast KAZO machine in foundry plant

2018 ◽  
Vol 204 ◽  
pp. 03007
Author(s):  
Rinaldi Sam Prabowo ◽  
Priyo Agus Setiawan ◽  
Anda Iviana Juniani ◽  
Wiediartini ◽  
Ika Erawati
Keyword(s):  
Risk Assessment ◽  
Reliability Analysis ◽  
Load Capacity ◽  
Vital Role ◽  
Metal Casting ◽  
Analysis Method ◽  
Risk Priority Number ◽  
Effect Analysis ◽  
A Value ◽  
Casting Industry

In a metal casting industry, Hanger Shot Blast KAZO machine plays a very vital role for blasting. The downtime equipment data for the last five years, 2013 to 2017, shows that the hanger shot blast KAZO is the machine which frequently encounters downtime with the number of 503,75 hours. As the only blasting machine with 2 (two) tons of load capacity, the issues of hanger shot blast KAZO affect to the targeted production process of company. Moreover, it increases risk of safety for the workers surround the machine. The purpose of this current research is to find out the reliability value of the item/ component of hover shot blast KAZO machine using Reliability Analysis method. The malfunction of its component is reviewed by FMEA (Failure Mode and Effect Analysis). While the risk assessment is obtained from RPN (Risk Priority Number) calculation - MTTF value and reliability value R(t). The result of this current study found that there are 21 malfunctions on hanger shot blast KAZO machine. MTTF analysis shows the highest MTTF value is 9195,324 hours for bearing impeller component and the lowest is 3498,997 hours for motor components. Meanwhile, reliability analysis shows that the largest reliability value with 0.999915 is encountered by motor contactor of crane, while with a value of 0.26385, hanger rotator motor contactor component encountered the lowest reliability value.

Analysing Reliability Aspects of HVAC Systems - A Case

2012 ◽  
Vol 488-489 ◽  
pp. 1813-1817
Author(s):  
Rajiv Kumar Sharma ◽  
Chandan Parbhot ◽  
Sidhant Thakur ◽  
Vivek Thakur
Keyword(s):  
Qualitative Analysis ◽  
Failure Modes ◽  
Reliability Assessment ◽  
Hvac Systems ◽  
Risk Priority Number ◽  
Effect Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Reliability Characteristics ◽  
Assessment Techniques

The general objective of this work is to analyze the failure of HVAC components in metro trains by using reliability assessment techniques. Various failure causes with respect to the electronic, electrical, hydraulic, pneumatic, software and mechanical components were identified. To improve upon the reliability characteristics of the system, in depth qualitative analysis of all HVAC units is carried out using Root cause analysis (RCA) and failure modes and effect analysis (FMEA) by listing all possible failure modes and their possible causes. Based on FMEA of components, Risk Priority Number (RPN) is calculated.

scholarly journals Applying MAC-F Method for Causes Analysis of the Proven Medication Error in a Moroccan Hospital

2020 ◽  
Vol 5 (2) ◽  
pp. 255-277
Author(s):  
Souad FILALI EL GHORFI ◽  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
High Reliability ◽  
Decision Support Tool ◽  
Root Cause Analysis ◽  
Organizational System ◽  
Cause Analysis ◽  
Support Tool ◽  
Root Cause ◽  
Overall Reliability

Medication error (ME) is a serious problem of public health. Difficulties related to the management of this error are numerous. Each stage of this process suffers from several flaws: identification, root causes analysis and improvement. This paper focuses on root cause analysis of medication error. We developed an original semi-quantitative method named “MAC-F (Méthode d’Analyse des Causes basée sur la Fiabilité globale, in French). It’s specific to the hospital context and constitutes a decision-making tool for professional of care. It based on a rigorous theoretical and conceptual framework (human reliability theory and high reliability organization theory). We used our method MAC F to analyze serious proven medication errors. They have been collected over the past six months (from January to June 2020) in Moroccan hospital. The reliability matrix shows that the overall reliability index is very low (Ω= 0,07). Moroccan hospital is therefore unreliable. The failure of the organizational system (Ω CF= 0,03) and the absence of preventive strategies (ΩIF= 0) don’t help practitioners to recover the medication errors (ΩSF= 0,23). Root cause analysis is the most critical step in managing medication errors. Our aim is to provide healthcare professionals with a decision support tool “MAC-F” that we believe will help them to prevent Medication Errors and to achieve overall reliability (reliable organization and practitioner). Our method was tested in a Belgian hospital before and Moroccan hospital recently.

scholarly journals Analytical performance assessment and improvement by means of the Failure mode and effect analysis (FMEA)

2020 ◽  
Vol 30 (2) ◽  
pp. 250-256
Author(s):  
Leonor Guiñón ◽  
Anna Soler ◽  
Luisa Alvarez ◽  
Aurea Mira ◽  
Josep Lluís Bedini ◽  
...  
Keyword(s):  
Failure Mode ◽  
Measurement Errors ◽  
External Quality Assessment ◽  
Risk Mitigation ◽  
Analytical Performance ◽  
Risk Priority Number ◽  
Effect Analysis ◽  
Root Cause ◽  
Analytical Errors

Introduction: Laboratories minimize risks through quality control but analytical errors still occur. Risk management can improve the quality of processes and increase patient safety. This study aims to use the failure mode and effect analysis (FMEA) to assess the analytical performance and measure the effectiveness of the risk mitigation actions implemented. Materials and methods: The measurands to be included in the study were selected based on the measurement errors obtained by participating in an External Quality Assessment (EQA) Scheme. These EQA results were used to perform an FMEA of the year 2017, providing a risk priority number that was converted into a Sigma value (σFMEA). A root-cause analysis was done when σFMEA was lower than 3. Once the causes were determined, corrective measures were implemented. An FMEA of 2018 was carried out to verify the effectiveness of the actions taken. Results: The FMEA of 2017 showed that alkaline phosphatase (ALP) and sodium (Na) presented a σFMEA of less than 3. The FMEA of 2018 revealed that none of the measurands presented a σFMEA below 3 and that σFMEA for ALP and Na had increased. Conclusions: Failure mode and effect analysis is a useful tool to assess the analytical performance, solve problems and evaluate the effectiveness of the actions taken. Moreover, the proposed methodology allows to standardize the scoring of the scales, as well as the evaluation and prioritization of risks.

scholarly journals Analisis Defect dengan Metode Fault Tree Analysis dan Failure Mode Effect Analysis

2019 ◽  
Vol 2 (2) ◽  
pp. 62-72
Author(s):  
Evan Nugraha ◽  
Rini Mulyani Sari
Keyword(s):  
Production Process ◽  
Failure Mode ◽  
Fault Tree ◽  
Fault Tree Analysis ◽  
Analysis Method ◽  
Risk Priority Number ◽  
Effect Analysis ◽  
Tree Analysis ◽  
Mode Effect ◽  
Failure Mode Effect Analysis

There was a phenomenon that occurred in garment companies, namely the existence of defect products in the production process. In the sewing process, defects occurred with an average percentage of 6,67% in the first three months of early 2019. This 6,67% was a percentage of disability that exceeded the company percentage limit of 5%, thus disrupting the production process. The primary purposed of analyzing the factors of product defects was to find out the causes and solutions to the company. The Fault Tree Analysis method was used to find out the root caused of product defects. Three main problems caused product defects, namely 1) untidy stitches, 2) stitches that exceeded the specified size, and 3) straightened stitches. By using the Failure Mode Effect Analysis method, the three problems were caused by human error and the absence of a Standard Operating Procedure in the production process. As a solution to problems in the company, the Risk Priority Number value was used. From this study the result obtained 1 Risk Priority Number value is the proposed improvement.

scholarly journals Effect and Associated Factors of a Clinical Pharmacy Model in the Incidence of Medication Errors in the Hospital Pablo Tobón Uribe Eacpharmodel Study: Stepped Wedge Randomized Controlled Trial (NCT03338725).

2021 ◽  
Author(s):  
Johan Granados ◽  
Pedro Amariles ◽  
Juan Pablo Botero-Aguirre ◽  
Natalia Andrea Ortiz-Cano ◽  
Andrés-Felipe Valencia-Quintero ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Clinical Pharmacy ◽  
Intervention Group ◽  
Pharmacy Practice ◽  
Hospitalized Patients ◽  
Care Process ◽  
Control Group ◽  
Randomized Controlled ◽  
The World

Abstract BackgroundThe World Health Organization considers medication errors to be an issue that requires attention at all levels of care, to reduce the severe and preventable harm related to drug therapy. In the world, clinical pharmacy practice standards have been proposed, where the pharmacist, as part of the multidisciplinary health team, can help improve patient safety; however, more and better evidence needs to demonstrate this effect. ObjectiveTo assess the change in the incidence of medication errors in hospitalized patients and thereby identify drug-related factors and problemsSettingThe study was conducted at Hospital Pablo Tobón Uribe, medellín, Colombia.MethodsA randomized, controlled cluster-wedge staggered trial with a duration of 14 months was conducted to compare the clinical pharmacy practice model's effect with the usual care process in the hospital. Five hospital health care units were included, which were initially assigned to the control group, and after an observation period of 2 months, they were randomly assigned to the intervention group.Main outcome measureIncidence of medication errors in hospitalized patientsResultsThe medication error incidence was 13.3% and 22.8% for the intervention group and control group, respectively. The probability of presenting medication error was 48% lower when the patient was in the intervention group (RR 0.52; 95% CI:0.34-0.79).ConclusionThe Clinical pharmacy practice model of the Hospital Pablo Tobón Uribe Hospital, made up of strategies focused on reducing medication errors, significantly reduces medication errors in patients during hospitalization compared to usual practice.

scholarly journals Descriptive Study on Reported Medication Error among Nurses in Queen Elizabeth II Hospital, Kota Kinabalu, Sabah

2020 ◽  
pp. 7
Author(s):  
Jenet Guan Chin ◽  
Mary Tan ◽  
Stephanie Yvonnesky Francis ◽  
Siti Rahmah Idris ◽  
Mary Padtong ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Continuous Monitoring ◽  
Descriptive Study ◽  
Precise Information ◽  
Root Cause ◽  
Preventative Measures ◽  
Global Issue ◽  
Reduce Medication Error

Introduction: Medication error is a global issue. Despite, the various impacts on health and non-health, continuous monitoring, assessment and intervention are required to reduce the number of medication error. Precise information on the root cause of medication error in Hospital Queen Elizabeth II, Kota Kinabalu will aid in the preventative measures to reduce medication error among nurses. Thus, this study aims to describe the incident of medication errors among nurses.

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