PDF DE CLIENTE CHEQUEADO POR 004_10792_Analisis modalde fallosy efectos_ING.indd 674 AMFE; Calidad; Seguridad; Administración; Jeringas. CLAVE PALABRAS administration; Oral control; Syringes. Safety; FMEA; Quality KEYWORDS them. reduce to measures the and safety patient on them, effects their cause that causes the risks, the analyse know to Conclusions: (RPN> 100). eight were the preventive implemented. of actions Seven Results: were proposed. ventive actions (RPN). Number using Risk failure Pre of the Priority calculated was mode with each associated failure errors. of impact cause can The that modes critical establishing potential most and the the identifying were analysed, liquid oral of administration of medication stages process The Committee. Methods: oral syringes. of use the Objective: Abstract 674 Eva Delgado-Silveira Emergency Deparment, Ramon y Cajal Hospital, Madrid. Spain. 1 Jesús María Aranaz-Andrés líquidos medicamentos para orales administrar jeringas de fallos utilización la de yefectos modal de Análisis syringes by oral medication ofliquid administration to the applied analysis effects and mode Failure Bilingual edition english/spanish ORIGINALS Ramon y Cajal Hospital, Madrid. Spain. Marta García-CollíaMarta Preventive Medicine Department, Ramon y Cajal Hospital, Madrid. Spain. l Farmacia Hospitalaria 2017 Vol. Vol. Five were high identified, failure as all risk classified modes A multidisciplinary team was assembled within the Safety within Safety the assembled was team Amultidisciplinary To carry out a Failure Mode and Effects Analysis (FMEA) to (FMEA) Analysis Effects and aFailure out To Mode carry 41 The FMEA methodology was a useful tool. It has allowed allowed has It tool. auseful was methodology FMEA The

l Nº Nº Farmacia Órgano oficial de expresión científica de la Sociedad Española de Farmacia Farmacia de Española Sociedad la de científica expresión de oficial Órgano HOSPITALARIA 6 l 5

2 , Eva María Guerra-Alia , Eva María 674 , Sonia Chamorro-Rubio , Sonia - 677 1 , Teresa Bermejo-Vicedo

l 4 Oncology Department, Ramon y Cajal Hospital, Madrid. Spain. 2 Servicio deServicio Farmacia, Hospital Ramón y Cajal, Madrid. Spain. 4 3 , Ángeles Fernández-Puentes , Ángeles 2 , Muñoz-Ojeda Isabel - del paciente; todo ello con el fin de implantar acciones para reducirlos. para acciones fin implantar el de con ello paciente;del todo seguridad la en tienen que efectos los ysaber provocar pueden los que analizar riesgos, causas las los conocer permitido útil ha rramienta que muy Conclusiones: implementadas. (NPR>100). riesgo alto de fueron recomendaciones ocho las de Siete Resultados: preventivas. acciones (NPR). riesgo de sugirieron Se utilizando prioridad número de el calculó se fallo de producir unerror. modo podrían acada El asociado riesgo que fallo de potenciales modos críticas yestableciendo más las cándose líquidos, administración la en medicamentos identifi los oral etapas de las Métodos: utilización ala orales. jeringas do de Objetivo: Resumen Hospitalaria 5 Biochemistry Department,Biochemistry Un grupo multidisciplinar dentro del Comité de Seguridad analizó analizó multidisciplinar Seguridad Comité grupo de Un del dentro Realizar un análisis modal de fallos y efectos (AMFE) aplica (AMFE) Realizar yefectos fallos unanálisis de modal 3 Accident and Se identificaron cinco modos de fallo, todos clasificados fallo,clasificados de identificaron cinco todos Se modos La aplicación de la metodología AMFE ha sido una he sido una ha AMFE metodología la Laaplicación de 2 4 , , Los artículos publicados en esta revista se distribuyen con la licencia la con distribuyen se revista esta en publicados artículos Los aceptado el 22 de junio de 2017. junio de 22 de el aceptado 2017; de marzo 6de el Recibido [email protected] Correo electrónico: 28034 Madrid. 9,100. km. Viejo Colmenar de Ctra. yCajal. Ramón Hospital Farmacia. de Servicio Muñoz-OjedaIsabel Author of correspondence DOI: 10.7399/fh.10792 DOI: La revista Farmacia no cobra tasas por el envío de trabajos, trabajos, de envío el por tasas cobra no Farmacia revista La https://creativecommons.org/licenses/by-nc-nd/4.0/ Articles published in this journal are licensed with a with are licensed journal in this published Articles ni tampoco por la publicación de sus artículos. sus de publicación la por ni tampoco Jesús María Aranaz-Andrés María Jesús al. et Creative Commons Attribution 4.0Creative Attribution Commons 06/11/2017 18:10 - - - PDF DE CLIENTE CHEQUEADO POR 004_10792_Analisis modalde fallosy efectos_ING.indd 675 nasogastric tube nasogastric oral syringes for the administration of oral medication orally or through of use the practice safety apriority as recommended (WHO) zation methadone in one case. as the intravenous administration of the oral solution for mucositis, or errors such medication of report the used, will after be oral syringes that ensure in to order study aFMEA-type conduct to decided has hospital tients in events pa severe for adverse acause represent way an incorrect specifically, administration their stage. Methods Introduction of liquid by medication oral syringes administration analysis applied to the Failure mode and effects and dispensing patients and hospitalized for prescription, medication validation of process hospital, the to applied liquid medications through oral administration administering and using preparing for of oral syringes importance the programs, highlighted which educational have and riodical newsletters liquid medications administration intravenous incidents which the involved oral of 33 safety for aresponse as generated was This tube. alert anasogastric of use required administration of the that way medications for incorrect to due regarding errors alert safety anational (NPSA), issued Agency Safety Patient (NHS), System National the through Health National the when ty organizations safe towards working patient international and national by care organizations; activity an increased therefore, been has there health for it Currently is management. apriority in quality component team, and all failure modes withteam, aRPN>100 all failure and modes were selected. within consensus by the chosen was point cut-off The detected). being of 10 to 1 (the highest likelihood detected) being of likelihood (the lowest afailure;likelihood detect to in this case, from avalue it assigned was tient) 10 to is the (catastrophic, possible). highest harm the Detectability pa the for from 1(no danger number Each failure aseverity received it occurs) 10 that to it occurs).probability that (the highest probability failurethe occur, to from 1 (the lowest avalue it and assigned was of probability the as defined was Frequency detectability. and verity frequency, multiplying by (RPN) se obtained was Number Risk Priority this for task. used was brainstormingtients. The method pa on effects potential their as well as were analyzed, originate them could that causes the and critical most weremedications, selected, the period. twelve-month within a planned was recommendations of a half. implementation The and hour with an approximate duration one of meetings face-to-face six of months, with 4 during aperiod conducted be to scheduled was its coordinator. was study The in this methodology an expert partments); De (from Oncology, the Emergency, Central Services and Cardiology supervisors four and mittee, including physicians, three pharmacists two with 1,070 hospital in atertiary methodology, beds. think that this type of error will never happen to them to will error happen of never think this type that they because or knowledge are or usingnals not lack to them, due either professio are available, not they healthcare where or centres still some in years, are recent there syringes these of use in an increase the been applied to administration to applied medications of Rodríguez-González by this article on topic, the publications as such risks, are there and different drug-associated analysis of the for mended is recom methodology FMEA-type The measures. prioritize correcting errors, any to of potential and this for failure, effects sons the assess to fail, can a process rea where the scenarios those identify allows to 1-3 The errors associated with the administration of medication through In Spain, the Institute for Safe Use of Medications (ISMP) publishes pe publishes (ISMP) Medications of Use Spain, Safe for In Institute the In order to estimate the risk associated with every failure mode, the with every risk associated the estimate to order In administration of stages oral for liquid the analyzed team work The Com within Safety the created was team work A multidisciplinary FMEA-type following the conducted, was study A prospective care, principle in patient is an essential acritical as well as Safety FMEA is a method for prospective and systematic analysis, which systematic and prospective for is amethod FMEA . Use of medications is one of the items to be reinforced, be to items the of is more and one medications of . Use 4 . One of the first alerts came up from the United Kingdom in 2007, Kingdom United upfrom the came first the alerts of . One 2 . 3 . During the same year, Organi same the . During World Health the ,8 7, . The Safety Committee of our of Committee Safety . The 6 , or those conducted in our conducted those , or 4,5 . Even though there has there though . Even 5 . ------Discussion Results Figure 1. and availability at hospitalization at units, availability and ensuring availability. their an After unit. the for stock in use the for Therefore, a reviewpolicy was there the of included been not had these or stock, of out was department supply the hospitalization unit, in available were the not oral syringes that because any comparisons. conduct to this to referred dication, device, has therefore it and study possible is no not administering of me process the analyze in to order methodology FMEA the the administration of oral medication. Even though other authors have used administration liquid for medications. oral of hospital, process in the improving increasing and use their safety 4,300 units 10mL for syringes. units 1mL, for 800 to from 1,600 4,200 to units 5mL from 1,700 for and to from 400 an increase hospitalization units by showed oral syringes of use the analysis of The nursing the by verified supervisors. this personally was nursing in a100% was the there unit syringes of rooms; availability storage hospitalization unit. each for in sessions their supervisors intranet; all the to by nursing it sent was controls, presented and them. conduct to strategy prevent the to errors and suggested actions effects, When analyzing the critical points, afailure the as we identified analyzing mode When for oral syringes of use the to first applied the FMEA described study Our at oral syringes of use the analysis of an in-depth allowed has FMEA that were it confirmed implemented, was recommendations these After (figure prepared was A poster Table Posterwithrecommendationsontheuse oforalsyringes.

1 shows the risk analysis results, the 1 shows stating failure cause, their modes, l Farmacia Hospitalaria 2017 Vol. Vol.

1) hospital the through disseminated and 41

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Table 1. Analysis of failure modes, effects and causes, in the use of oral syringes for oral administration of medications. 676

Risk Analysis Actions and results l Farmacia Hospitalaria 2017 Vol. Vol. 41

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Failure modes Causes Effects Action Responsible Deadline Nº Saverity (S) RPN (F*S*D) Detection (D) Frequency (F) Frequency 6 l

674

Policy of use and recommendation -

No stock at Supplies. of use mandatory for the Nursing 677 No availability at The supervisor does not include stock The promotion of the use Management. Chief of the Safety the Hospitalization in the Agreement for Use. of a safety device is not 9 6 8 432 Include in the annual objectives for 2016 l Committee Units. Their use has not been widely achieved. Nursing Units. adopted. Review of the availability at hospitalization units.

Place the oral syringes in the area for preparing medication. Chief of the Safety Insufficient communication between Oral medication might Insufficient access Training. Committee. supervisor and nurse, and between get administered 9 6 7 378 2016 to syringes. Awareness posters. Hospital Ramón y nurse and student. intravenously. Update in the protocol for oral Cajal Pharmacists. medication administration.

The supervisor is not aware of the Training. Oral medication might Chief of the Safety Lack of knowledge existence of syringes. Awareness posters. get administered 8 6 8 384 Committee. 2016 of their existence. The supervisor does not inform the Update in the protocol for oral intravenously. ICU Supervisor. nurse about their existence. medication administration.

Difficulties for labelling syringes. The device does not meet the expectations by professionals The promotion of the use Standardize the process of use of Chairwoman of the Difficulties in (adequate material due to the tip of a safety device is not 8 7 8 448 oral syringes. Safety Committee. 2015

syringe handling. Aranaz-Andrés María Jesús al. et lumen / syringe colour). achieved. Establish as Mandatory Rule. Supervisor Difficulties to use the oral syringe in nasogastric tubes due to their port.

The promotion of the use of a safety device is not Training. Low perception of risk. Chairwoman of the Resistance to achieved. Awareness posters. Excessive trust in “what has always 8 6 8 384 Safety Committee 2015 change Oral medication might Update in the protocol for medication been done”. Hospital Pharmacists. get administered administration. intravenously. 06/11/2017 18:10 PDF DE CLIENTE CHEQUEADO POR 004_10792_Analisis modalde fallosy efectos_ING.indd 677 Bibliography us by in routine. working their conducted practice safer aprevious In study this of entire an inclusion to the by staff contributed professionals, have training, of in terms adopted an improved and communication between hospital. the at use their of assuming ahigher implementation to which led use, observed, was an increase subsequent their analysis of of liquid by medication oral syringes administration analysis applied to the Failure mode and effects Committee. Committee. the for objective apending as This remained established. task deadline the by said implementation complete to it difficult whichCommittee, made Safety and in Nursing Management staff of achange was there process administration, medication implementation for during the protocol because hospitalization unit. in each sessions through professionals train to it essential was that considered Committee thisIn Safety sense, the safe. time are necessarily along for not conducted been have that practices certain risk, that the which of accepting prevents perception low and dence in confi with an excess entire organization. associated This is closely also in the even acultural change and is required everyone, by effort a major purchased. be to oral syringes the of management tube); this an adequate by overcome was (such as, devices to example, for nasogastric adaptation the poor of cause process. 4. 3. 2. 1. 7 , it was considered essential to train to in involved the all professionals essential , it considered was

Regarding the “lack of knowledge of their existence”, their of knowledge of Regarding “lack the measures the The only measure that could not be implemented was an update in the in the an update was implemented be not could that measure only The Regarding in habits, working resistance routines and achange to the be in handling syringes difficulty the was detected problem Another pana.org/ficheros 29.Boletín 26/06/2015). 2009. Mayo, (Consultado en:http:/ismes Disponible vía intravenosa. Recomendaciones para la prevención de errores de medicación. ISMP-España. Errores por administración de medicamentos orales líquidos por nhs.uk/resources 2007.March, 28/09/2015). (Consultado http://www.nrls.npsa. en Disponible routes. enteral other and oral via liquid medicines of administration and rement 19. Alert measu safer Patient Safety Agency. Promoting Patient Safety National patientsafety/PS-solution7.pdf 25/09/2015).sultado en http://www.who.int/patientsafety/solutions/ Disponible 7. Solution Solutions. 2007. May Patient Safety mis-connections. tubing (Con and Avoiding catheter Patient Safety. for Alliance World Organization. Health World 30/09/2015). Disponible en http://www.ismp-canada.org/ 2002. January, (Consultado Bulletin. Safety Canada ISMP injection. by solutions oral of administration Inadvertent Canada. Practices Medication Safe for Institute - - - - - Conflict of interests Conflict Acknowledgements Funding and to the Pharmacy Unit specialists. Pharmacy the to and said risks. reduce in to order actions implementing and issuing of recommendations safety, objective with the patient on effects administration their as well as liquid causes their of medications, analyze to with the failures the associated risks and understand to allowed has that 6. 5. 8. 7. Contribution to scientific literature literature to scientific Contribution oral medication. administration of liquid for process in the safety increase in to order tool administration setting. hospital the in for the oral medication of syringes

The authors hereby declare that there is no conflict of interests whatsoever. interests of is conflict there no that declare hereby authors The the of members all to the thanks Our this for article. received been funding has No tool useful a very been has methodology FMEA the of application The ISMP-España. Uso de jeringas orales para administrar medicamentos orales líqui orales medicamentos administrar para orales jeringas de Uso ISMP-España. validation and dispensing in hospitalised patients. BMJ Qual Saf. 2013;22:42-52. Qual BMJ patients. in hospitalised dispensing and validation prescription, drug of process in the errors medication reduce to Analysis Effect and Failure Mode E, T, E. Carretero Healthcare Using Vélez Bermejo M, Delgado 2012;36:24-32. Hosp. Farm medicamentos. de ydispensación validación prescripción, de proceso del yefectos fallos de T. Bermejo modal Análisis MA, E, J, Pérez Rodríguez A, Álvarez C, Serna Delgado ClinEval Pract. 2015;21:549-59. J process. administration medication in the safety improve to analysis criticality and effect failure mode, P, of Use M. Sanjurjo-Saez Hernández-Sampelayo MI, quez Durango-Limar A, Herranz-Alonso ML, CG, Martín-Barbero Rodríguez-González sinasp.es/acrs 35. 2012. Octubre, 25/09/2015). (Consultado https://www. en Disponible Boletín medicación. de errores de prevención la para Recomendaciones tada. implan suficientemente está no que prioritaria seguridad de práctica dos: una The application of the FMEA methodology has been a very useful useful avery been has methodology FMEA the of application The oral of use the to applied aFMEA describe to This first is the study l Farmacia Hospitalaria 2017 Vol. Vol. 41 Ramón yCajalRamón

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