International Journal of Clinical Pharmacy

, Volume 36, Issue 5, pp 953–962 | Cite as

Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge

  • Laure-Zoé KaestliEmail author
  • Laurence Cingria
  • Caroline Fonzo-Christe
  • Pascal Bonnabry
Research Article


Background Discharging patients from hospital is a complex multidisciplinary process that can lead to non-compliance and medication-related problems. Objective To evaluate risks of discontinuity of pharmaceutical care at paediatric hospital discharge and assess potential improvement strategies, using two complementary methods: a prospective risk analysis and a spontaneous incident reporting system. Setting Geneva University hospitals and community pharmacies. Methods A multidisciplinary team analysed the paediatric medication discharge process applying the failure modes (FM), effects, and criticality analysis (FMECA), using ibuprofen, morphine, valganciclovir as model drugs. Over 46 months, incidents with discharge prescriptions, reported by community pharmacists, were classified according to FMECA’s FM. Main outcome measures FM, criticality indexes (CI), incidents. Results Twenty-four FM were identified. The highest criticality scores were given for prescribing the wrong dosage [mean criticality index (CI = 205)], early treatment discontinuation by the patient (CI = 195), and continuation of contraindicated treatment by the general practitioner (CI = 191). Implementation of eight improvement strategies covering the eight most critical FM led to a 64 % reduction in criticality scores (CI 496 vs 1,392). Improvement of the computerized-physician-order-entry system was the single most effective strategy (CI 843 vs 1,392). Only 52 incidents were spontaneously reported (17 for paediatric patients). Paediatric problems most frequently reported (lack of information, 35 %; delay in drug supply, 18 %) were consistent with the highest frequencies scored by FMECA. Conclusion Spontaneous incident reporting leads to high levels of under-reporting, but highlighted similar problems at paediatric hospital discharge to FMECA. Using FMECA allowed estimations of criticalities at each step and the potential impact of safety improvement strategies. Proactive and reactive methods proved complementary and would help to set up effective targeted improvement strategies to improve medication process at paediatric hospital discharge.


Hospital discharge Incident reporting Paediatrics Proactive risk assessment Switzerland 



.The author would like to thank Mrs. A. De Rosso (paediatric hospital nurse), Dr. JF Babel (paediatrician in hospital and community), P. Osiek-Lecomte and C. Burgnard (community pharmacists) and Mrs. S. Grimonet (mother of a sick child) who took part in the FMECA analysis.


This research was supported by an unrestricted Grant from pharmaSuisse, the Swiss society of pharmacists.

Conflicts of interest



  1. 1.
    Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients: development of a discharge checklist for hospitalists. J Hosp Med. 2006;1:354–60.PubMedCrossRefGoogle Scholar
  2. 2.
    Kripalani S, et al. Medication use among inner city patients after hospital discharge: patient reported barriers and solutions. Mayo Clin Proc. 2008;83:529–35.PubMedCrossRefGoogle Scholar
  3. 3.
    Groene RO, Orrego C, Suñol R, et al. “It’s like two worlds apart”: an analysis of vulnerable patient handover practices at discharge from hospital. BMJ Qual Saf. 2012;21:67–75.CrossRefGoogle Scholar
  4. 4.
    Clarke C, Persaud D. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. J Patient Saf. 2011;7:11–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Jeffcott SA, Evans SM, Cameron PA, et al. Improving measurement in clinical handover. Qual Saf Health Care. 2009;18:272–7.PubMedCrossRefGoogle Scholar
  6. 6.
    WHO. Action on patient safety—high 5 s Accessed Jan 2013.
  7. 7.
    Wong IC. Supply problems of unlicensed and off-label medicines after discharge. Arch Dis Child. 2006;91:686–8.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Kunac DL, Kennedy J, Austin N, et al. Incidence, preventability, and impact of Adverse Drug Events (ADEs) and potential ADEs in hospitalized children in New Zealand: a prospective observational cohort study. Paediatr Drugs. 2009;11:153–60.PubMedCrossRefGoogle Scholar
  9. 9.
    Matsui D. Current issues in pediatric medication adherence. Paediatr Drugs. 2007;9:283–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Ashley L, Armitage G, Neary M, et al. A practical guide to failure mode and effects analysis in healthcare: making the most of the team and its meetings. JE Comm J Qual Patient Saf. 2010;36:351–8.Google Scholar
  11. 11.
    Institute for healthcare improvement. Failure modes and effects analysis (FMEA). Accessed Jan 2013.
  12. 12.
    Bonnabry P, Cingria L, Sadeghipour F, et al. Use of a systematic risk analysis method to improve security in the pediatric parenteral nutrition production. Qual Saf Health Care. 2005;14:93–8.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Bonnabry P, Cingria L, Ackermann M, et al. Use a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int J Qual Health Care. 2006;18:9–16.PubMedCrossRefGoogle Scholar
  14. 14.
    Bonnabry P, Despond-Gros C, Grauser D, et al. A risk analysis method to evaluate the impact of a computerized provider order entry system on patient safety. J Am Med Inform Assoc. 2008;15:453–60.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    De Giorgi I, Fonzo-Christe C, Cingria L, et al. Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units. Int J Qual Health Care. 2010;22:170–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care. 2009;18:11–21.PubMedCrossRefGoogle Scholar
  17. 17.
    Terezakis SA, Harris KM, Ford E et al. An evaluation of departmental radiation oncology incident reports: anticipating a national reporting system. Int J Radiat Oncol Biol Phys. 2012;85:919–23.PubMedCrossRefGoogle Scholar
  18. 18.
    Tighe CM, Woloshynowych M, Brown R, et al. Incident reporting in one UK accident and emergency department. Accid Emerg Nurs. 2006;14:27–37.PubMedCrossRefGoogle Scholar
  19. 19.
    Vincent C, Taylor-Adams S, Stabhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    WHO. WHO draft guidelines for adverse event reporting and learning systems: from information to action. Geneva: World Health Organization, World alliance for patient safety, 2005 Accessed Jan 2013.
  21. 21.
    Kousgaard MB, Joensen AS, Thorsen T. Reasons for not reporting patient safety incidents in general practice: a qualitative study. Scand J Prim Health Care. 2012;30:199–205.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    William E, Talley R. The use of failure mode effect and criticality analysis in a medication error subcommittee. Hosp Pharm 1994; 29:331–2, 334–6, 339.Google Scholar
  23. 23.
    Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics. 2004;113:59–63.PubMedCrossRefGoogle Scholar
  24. 24.
    Wang JK, Herzog NS, Kaushal R, Park C, Mochizuki C, Weingarten SR. Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry. Pediatrics. 2007;119:e77–85.PubMedCrossRefGoogle Scholar
  25. 25.
    Shebl NA, Franklin B, Barber N, et al. Failure mode and effect analysis: views of hospital staff in the UK. J Health Serv Res Policy. 2012;17:37–43.PubMedCrossRefGoogle Scholar
  26. 26.
    Shebl NA, Franklin BD, Barber N. Failure mode and effects analysis outputs: are they valid? BMC Health Serv Res. 2012;12:15.CrossRefGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014

Authors and Affiliations

  • Laure-Zoé Kaestli
    • 1
    • 2
    Email author
  • Laurence Cingria
    • 1
  • Caroline Fonzo-Christe
    • 1
  • Pascal Bonnabry
    • 1
    • 2
  1. 1.PharmacyGeneva University HospitalsGeneva 14Switzerland
  2. 2.School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland

Personalised recommendations