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Failure-mode and effects analysis in improving a drug distribution system

K M McNally1, M A Page, V B Sunderland

  • 1School of Pharmacy, Curtin University of Technology, Perth, Western Australia. tsunderlv@cc.curtin.edu.au

American Journal of Health-System Pharmacy : AJHP : Official Journal of the American Society of Health-System Pharmacists
|January 15, 1997
PubMed
Summary

A new drug distribution system significantly reduced medication errors in an Australian hospital. Failure-mode and effects analysis (FMEA) identified ward stock system flaws, leading to a unit supply individual-patient dispensing (USIPD) system with fewer errors.

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Area of Science:

  • Pharmacy and Therapeutics
  • Patient Safety
  • Health Systems Research

Background:

  • The traditional ward stock drug distribution system in hospitals can lead to medication errors.
  • Identifying and rectifying systemic flaws is crucial for improving patient safety.

Purpose of the Study:

  • To compare medication error rates between a conventional ward stock system and an improved unit supply individual-patient dispensing (USIPD) system.
  • To utilize Failure-Mode and Effects Analysis (FMEA) to identify and address deficiencies in the ward stock system.

Main Methods:

  • A disguised-observer technique was employed by a pharmacist to quantify medication errors in both medical and surgical wards.
  • Failure-Mode and Effects Analysis (FMEA) was conducted to scrutinize each step of the ward stock system.

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  • A unit supply individual-patient dispensing (USIPD) system was developed and implemented, dispensing a five-day supply of individually labeled medications to patients' bedside.

    • Main Results:

    • FMEA identified key problem areas in the ward stock system, including drug availability, order review, drug selection, patient-specific issues, and nursing workload.
    • The implementation of the unit supply individual-patient dispensing (USIPD) system resulted in a statistically significant reduction in the percentage of opportunities for medication errors on both medical and surgical wards.

    Conclusions:

    • Failure-Mode and Effects Analysis (FMEA) is an effective tool for identifying medication errors within hospital drug distribution systems.
    • The unit supply individual-patient dispensing (USIPD) system offers a safer alternative to traditional ward stock systems, demonstrably reducing medication errors.