Student Dissertation

Agency :

Objective : To review the medication management process of the hospital and identify the potential failures in the process so as to propose policy recommendations to minimize the medication errors.

Background : An effective medication management system includes proactive assessment of risk points in each process as well as risk associated with integration of these functions. It is important for everyone involved in the medication process to understand the process and the risk points involved. After risks have been identified, safety nets can be incorporated to reduce the probability that an adverse event will occur, increase the chance that the problem or error will be averted before it reaches the patient, or decrease the risk of event causing harm.

Methodology : To track the medication management process data was collected using secondary data and primary data. The whole study was conducted in 4 phases - phase 1: process mapping, check the flow chart for accuracy in sequence and relationship, phase 2: identifying the failure modes, phase 3: prioritizing the failure modes by calculating risk priority number for each mode based on its severity, frequency and detection, phase 4: policy recommendations to minimize or eliminate the failures. The tool used is FMEA (Failure Mode Effect Analysis).

Findings : Five failure modes were prioritized on the basis of RPN i.e. the drug is transcribed wrongly on the treatment sheet (RPN -324), drugs are not cross checked against the order for the right dosage as indented (RPN- 252), incorrect administration time are listed on the treatment sheet (RPN- 240), wrong dosage is dispensed (RPN- 196), prepares incorrect dosage, incorrect drug, incorrect medication (RPN- 189). The major causes for these failure modes were illegible handwriting, miscommunication of drug orders, non adherent to policies and procedures, failure of double checks the order received against the drugs prescribed, lack of proper labeling of drugs when dispensed from the pharmacy, negligence (performance deficit, knowledge deficit, and mental slip)

Recommendations : Computerized physician order entry (CPOE), training motivation, labeling of drugs and adherence to policies and procedures.

To review the medication management process of the hospital and identify the potential failures in the process so as to propose policy recommendations to minimize the medication errors.


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