Student Dissertation

Agency : Medication Management process, Risk Priority Number, Computerised Physician Order Entry.

Objective : To review the medication management process from the time of prescribing medicine till administration, to identify and prioritize the risks so as to propose recommendations for ensuring patient safety.

Methodology : The study was a cross sectional descriptive study in a private hospital. A purposive sampling of 50 respondents was taken including doctors & nurses. A detailed medication management process was studied to track the failure modes where the chances of error occur. The primary data was collected through observations, interviews and with the help of questionnaire both for nurses and doctors for calculating risk priority number based on severity, detection and frequency

Findings : On reviewing the medication process in detail for medication management process, 17 failure modes were identified. The cause and its effects of these failure modes were analyzed and scoring was done based on severity, detection and frequency scale. Out of these five failure modes were prioritized on the basis on RPN. The major cause of error was allergy not documented, incorrect labeling/ instruction (LASA), Omitted/ Missed Drug/ Dose, Incorrect Dilution / Calculation, Incorrect Strength / Concentration & Incorrect Route. Conclusion: In the study of Medication Management Process the major failure modes were identified and preventive action has been taken in form of CPOE, Prescription Audit, and Medication management checklist. In case of corrective action, medication error reporting form has been introduced to document the same.

Recommendations :

The issue of human errors in complex systems has been a topic of debate for decades. Making mistakes is human nature and cannot be eradicated. What can be changed, however, are the conditions under which humans work. Adverse medical events, as injuries to patients that arise from mistakes and accidents during medical treatment are called, can be result of human errors, technological errors, or a system that failed to detect these mishaps and prevent them. Achieving patient safety is a foremost goal among healthcare workers.


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