Citation Information :
Prakash R, Sharma S, Sharma A. Healthcare Failure Mode and Effect Analysis: Dispensing Errors in the Pharmacy of an Outpatient Department of a Public Sector Tertiary-care Teaching Hospital. Int J Res Foundation Hosp Healthc Adm 2019; 7 (1):11-18.
Background: Dispensing failures mean that a breach has occurred in one of the last safety links in the use of drugs. Although most failures do not harm patients, their existence suggests fragility in the process and indicates an increased risk of severe accidents.
Materials and methods: To address these gaps in our understanding of dispensing errors, we conducted a direct observational study to determine the various failure modes, categorize the types of errors, and evaluate their potential to cause patient harm using healthcare failure mode and effect analysis (HFMEA).
Results: The high-risk failure modes identified were as follows: patient unable to understand the prescription, illegible prescription, medication dispensed to wrong patient, counseling about new dose does not occur or ineffective, and patient taking incorrect dose.
Conclusion: None of the steps in the drug-dispensing process were free of potential failure modes, but six failure modes emerged as the most vulnerable steps [with risk priority numbers (RPNs) over 168]. The most critical elements in the dispensing of drugs in the present setting were where patient does not understand proper use of prescription of potentially dangerous drug interaction (RPN 432) followed by illegible prescription. There is a dire need of application of systems theory with actions needed at every level of drug dispensing mechanism. Quality tools such as HFMEA and root cause analysis are warranted to forecast various failure modes and to find out root causes of adverse events that happen.
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