Student Dissertation

Agency : Medication Management Process; Failure Modes; FMEA; Medication; Medication Errors

Objective : To review the medication management process through process mapping. To identify the various failure modes in the process with their severity and frequency. To analyze the causes and effects of various failure modes. To propose recommendations to eliminate the failures from the process in order to minimize medication errors.

Background : The reality that medical treatment can harm patients is one that the healthcare community has come to terms with over recent years. Medications are involved in 80 percent of all treatments and impact every aspect of a patient's life. In particular, adverse events associated with medication appear among the chief causes of this. Prescribing and drug administration appear to be associated with the greatest number of medication errors (MEs), whether harm is caused or not. Recent systematic reviews of medication administration error (MAE) prevalence in healthcare settings found that they were common, with one reporting an estimated median of 19.1 % of ‘total opportunities for error’ in hospitals. A significant proportion of MA

Methodology : TYPE OF STUDY- Observation analytical study STUDY LOCATION- Rockland Hospital, Dwarka SOURCE OF DATA COLLECTION Primary Data- Direct observation of prescriptions and interaction with nurses. Secondary Data- Previous patient records STUDY SAMPLE- IPD January,2016-643 IPD Feb,2016- 683 IPD March,2016- 651 Population Frame 1977 Sample size =266 STUDY DURATION- THREE MONTHS STUDY TOOL- FMEA (Failure Mode Effect Analysis)

Findings : From the study the most common causes of Failure were identified as: Illegible Handwriting- It includes use of incorrect abbreviations, confusion between drugs with similar names, misuse of zeroes & decimal points and unclear prescriptions. Delay in dispensing of order from pharmacy Improper/Incomplete order is dispensed from pharmacy Miss communication of drug orders. Cross checking of order was not done by the nurse Nurse did not sign the patient sheet after dispensing the medication. Medication was not administered on proper time. Nonadherent to policies and procedures Negligence (Performance deficit, knowledge deficit, mental slip)

Recommendations : There are number of factors at each step of patient care that contribute to medication errors Special focus should be given to the prescription & transcriptase phases of patient care due to large number of errors tracked back to these stages of treatment Policies & Procedures are in place, just adherence to them is required. Training & motivation is the need of hour, should be ascribed priority and promptly addressed. FMEA is a continuous process and should be improved in phases The recommended actions are to be taken along with defined responsibilities.


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