[Post-hoc analyses of adverse events in the retrocession sector: Toward a priori risk analysis]

Risk management is critical to ensuring the security of hospital outpatient medication dispensing, and the associated tools must align with the broader hospital quality management system. The primary objective is to optimize dispensing processes in terms of safety and the quality of care provided. Two complementary risk analysis methods were employed within an established retrocession framework: a retrospective analysis of adverse events and a prospective risk analysis using the failure mode, effects, and criticality analysis method. Adverse events were categorized by error type and subprocess, and the conditions surrounding their occurrence and detection were carefully examined. Error types were incorporated into a prospective risk analysis which was developed according to a process-oriented approach. Regular team meetings, in conjunction with the initial prospective risk analysis, facilitated the identification of additional failure modes and the refinement of risk ratings. Over a two-year period, 130 adverse events, 14 distinct error types, and 90 potential failure modes were identified. A comprehensive list of preventive and corrective actions was subsequently formulated. Pharmaceutical analysis, including patient consultation, was identified as a key step in enhancing the safety of the care pathway. Furthermore, double pharmaceutical verification and continuous staff training remain essential to ensure ongoing safety. External adverse events, if undetected, can lead to internal failures, underscoring the importance of heightened awareness among staff and stakeholders. This study has contributed to enhancing patient pathway safety, improving risk management processes, and strengthening the process-oriented approach.