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Application of failure mode and effects analysis (FMEA) to improve medication safety in the dispensing process - a
J A L Anjalee1,2, V Rutter3, N R Samaranayake4
1Colombo South Teaching Hospital, Kalubowila, Dehiwala, Sri Lanka.
Background:
Failure mode and effects analysis (FMEA) is a prospective, team based, structured process used to identify system failures of high risk processes before they occur. Medication dispensing is a risky process that should be analysed for its inherent risks using FMEA. The objective of this study was to identify possible failure modes, their effects, and causes in the dispensing process of a selected tertiary care hospital using FMEA.
Methods:
Two independent teams (Team A and Team B) of pharmacists conducted the FMEA for two months in the Department of Pharmacy of a selected teaching hospital, Colombo, Sri Lanka. Each team had five meetings of two hours each, where the dispensing process and sub processes were mapped, and possible failure modes, their effects, and causes, were identified. A score for potential severity (S), frequency (F) and detectability (D) was assigned for each failure mode. Risk Priority Numbers (RPNs) were calculated (RPN=SxFxD), and identified failure modes were prioritised.
Results:
Team A identified 48 failure modes while Team B identified 42. Among all 90 failure modes, 69 were common to both teams. Team A prioritised 36 failure modes, while Team B prioritised 30 failure modes for corrective action using the scores. Both teams identified overcrowded dispensing counters as a cause for 57 failure modes. Redesigning of dispensing tables, dispensing labels, the dispensing and medication re-packing processes, and establishing a patient counseling unit, were the major suggestions for correction.
Conclusion:
FMEA was successfully used to identify and prioritise possible failure modes of the dispensing process through the active involvement of pharmacists.
Insights
Failure mode and effects analysis (FMEA) identified high-risk medication dispensing failures. Pharmacist involvement in FMEA successfully prioritized corrective actions to enhance patient safety in hospital settings.
Area of Science:
- Healthcare Management
- Patient Safety
- Pharmaceutical Sciences
Background:
- Medication dispensing is a high-risk process prone to system failures.
- Failure Mode and Effects Analysis (FMEA) is a structured approach to proactively identify potential risks.
- Applying FMEA to medication dispensing can enhance safety and prevent adverse events.
Purpose of the Study:
- To identify potential failure modes, their effects, and causes within a hospital's medication dispensing process.
- To utilize Failure Mode and Effects Analysis (FMEA) for risk assessment in pharmaceutical dispensing.
- To prioritize identified failure modes for corrective actions.
Main Methods:
- Two independent teams of pharmacists conducted FMEA over two months.
- Processes were mapped, and failure modes, effects, and causes were identified.
- Severity, Frequency, and Detectability scores were assigned to calculate Risk Priority Numbers (RPNs) for prioritization.
Main Results:
- A total of 90 unique failure modes were identified across both teams.
- Overcrowded dispensing counters were a common cause for numerous failure modes.
- Key recommendations included redesigning dispensing areas, labels, processes, and establishing a patient counseling unit.
Conclusions:
- FMEA proved effective in identifying and prioritizing potential failure modes in medication dispensing.
- Active pharmacist involvement is crucial for successful FMEA implementation.
- The study highlights FMEA's utility in improving medication dispensing safety.
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