Effect of Healthcare Failure Mode and Effect Analysis on Reducing Error Risk of Neonatal Parenteral Nutrition Solution Dispensing

[Objectives]To investigate the effect of healthcare failure mode and effect analysis(HFMEA)on reducing error risk of neonatal parenteral nutrition solution dispensing.[Methods]A research team was established to identify the failure mode(FM)in each link of the formulation process of neonatal parenteral nutrition solution by HFMEA,quantify the severity(S),occurrence(O)and detection(D)of FM,and evaluate FM by risk priority number(RPN).For FM with the values of RPN>16,failure cause analysis was conducted,and corresponding improvement measures were formulated.The weight coefficient and random consistency ratio(CR)of deployment process were calculated in Matlab R2018a by compiling the Analytic Hierarchy Process(AHP)program.Six months after the implementation of improvement measures,the implementation effect was evaluated by comparing the changes of the values of RPN which was evaluated comprehensively and the rate of dispensing errors before and after the implementation of HFMEA.[Results]In the preparation process of neonatal parenteral nutrition solution,a total of 13 FMs with medium and above risk were found,the weight coefficient of medical order review,dosing and mixing was 0.2703,the weight coefficient of drug dispensing check and review was 0.1432,the weight coefficient of print label was 0.1015,the weight coefficient of distribution was 0.0716,and CR=0.0491<0.1.After six months of intervention,the total RPN value decreased by 64.81%from 127.8 to 45.0.The deployment error rates were significantly lower after the implementation,and the difference was statistically significant(P<0.05).[Conclusions]HFMEA can effectively reduce the error risk in preparation of neonatal parenteral nutrition solution,improve the quality of dispensing and promote the safety of neonatal medication.

Knowledge,attitude,and practices related to medication errors among nursing professionals:a questionnaire-based study in a tertiary care hospital

Objective:To evaluate the level of understanding(knowledge),beliefs(attitude),and behavior(practice)of staff nurses toward medication errors(MEs).Methods:Self-administered questionnaires were distributed to nursing professionals who had at least 1 year of work experience.Each questionnaire contained 19 items assessing“knowledge,”“attitude,”and“practice”attributes toward MEs.Results:Responses from 47 nursing respondents were included for the final analysis.The mean knowledge score was 3.8±1.1(out of 6);66%and 79%of the respondents had awareness of medication repor ting systems and interventions in preventing MEs,respectively.Lack of adequate knowledge in recognizing MEs(P=0.003),or presuming MEs are not as important enough to be reported(P=0.002),was considered as the major reason for under-repor ting of MEs.Nurses with higher knowledge score were against administration of medication through a different route than that prescribed by the physician(P=0.023),and tried to rectify an ME(P=0.020)and stayed with the patient until an oral medication had been swallowed(P=0.037).Conclusions:The nursing professionals were aware of the ME repor ting system and methods to prevent the occurrence of MEs.They also exhibited a positive attitude and followed optimal practices in controlling MEs.