Abstract
According to the 2000 Institute of Medicine Report on Building a Safer Health System, experts estimated that 8000 Americans die every year from preventable medication errors. It is believed that these errors annually affect more than 7 million patients with the cost of approximately $21 billion across all care settings. Despite some developed studies on analyzing the contributing causes of medication errors, there is a need for the development of more robust, systematic methodologies to identify their root causes and provide preventive measures to avoid their recurrence. This paper proposes a methodology, which is an integration of Failure Modes and Effects Analysis (FMEA) and Fault Tree Analysis (FTA), to first identify one of the top most important categories of medication error and then analyze its contributing and root causes. In this study, we develop FTA for administration errors, as they are highly occurring and very severe among other medication error categories.
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Kohn, L.T., Corrigan, J.M., Donaldson, M.S., McKay, T., Pike, K.C.: To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America. Institute of Medicine. National Academy Press, Washington, D.C. (2000)
Phillips, D.P., Christenfeld, N., Glynn, L.M.: Increase in US medication-error deaths between 1983 and 1993. Lancet 351, 643–644 (1998)
Bindler, R., Baynd, T.: Medication calculation ability of registered nurses. J. Nurs. Scholarsh. 23(4), 221–224 (1991)
da Silva, B.A., Krishnamurthy, M.: The alarming reality of medication error: a patient case and review of Pennsylvania and National data. J. Community Hosp. Intern. Med. Perspect. 6(4) (2016). https://doi.org/10.3402/jchimp.v6.31758
Aronson, J.: Medication errors: what they are, how they happen, and how to avoid them. QJM: Int. J. Med. 102, 513–521 (2009). https://doi.org/10.1093/qjmed/hcp052
Manasse, H.R.: Medication use in an imperfect world: drug misadventuring as an issue of public policy, part 1. Am. J. Hosp. Pharm. 46, 929–944 (1989)
Barber, N., Rawlins, M., Franklin, B.D.: Reducing prescribing error: competence, control and culture. Qual. Saf. Health Care 12, 129–132 (2003)
Fahimi, F., Ariapanah, P., Faizi, M., Shafaghi, B., Namdar, R., Ardakani, M.: Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study. Aust. Crit. Care 21, 110–116 (2008)
Bohand, X., Simon, L., Perrier, E., Mullot, H., Lefeuvre, L., Plotton, C.: Frequency, types, and potential clinical significance of medication-dispensing errors. Clinics 64(1), 11–16 (2009)
Gladstone, J.: Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J. Adv. Nurs. 22, 628–637 (1995)
Kumar, S., Steinebach, M.: Eliminating US hospital medical errors. Int. J. Health Care Qual. Assur. 21(5), 444–471 (2008)
Al-Kuwaiti, A.: Application of Six Sigma methodology to reduce medication errors in the outpatient pharmacy unit: a case study from the King Fahd University Hospital, Saudi Arabia. Int. J. Qual. Res. 10(2), 267–278 (2016)
Buck, C.: Application of Six Sigma to reduce medical errors. In: ASQ World Conference on Quality and Improvement Proceedings, p. 739. American Society for Quality, January 2001
Teixeira, T.C., de Cassiani, S.H.: Root cause analysis: evaluation of medication errors at a university hospital. Rev. Esc. Enferm. USP 44, 139–146 (2010). https://doi.org/10.1590/s0080-62342010000100020
Chiozza, M.L., Ponzetti, C.: FMEA: a model for reducing medical errors. Clin. Chim. Acta 404, 75–78 (2009)
Montesi, G., Lechi, A.: Prevention of medication errors: detection and audit. Br. J. Clin. Pharmacol. 67, 651–655 (2009)
Comden, S.C., Marx, D., Murphy-Carley, M., Hale, M.: Using probabilistic risk assessment to model medication system failures in long-term care facilities. In: Henriksen, K., Battles, J.B., Marks, E.S., Lewin, D.I. (eds.) Advances in Patient Safety: From Research to Implementation. Concepts and Methodology (AHRQ Publication No. 05–0021–2. Section: Cognition, Systems, and Risk), vol. 2, pp. 395–408. Agency for Healthcare Research and Quality, Rockville (2005)
Cherian, S.M.: Fault tree analysis of commonly occurring medication errors and methods to reduce them. Texas A&M University (1994)
Mansouri, A., Ahmadvand, A., Hadjibabaie, M., Kargar, M., Javadi, M., Gholami, K.: Types and severity of medication errors in Iran; a review of the current literature. DARU 21, 49 (2013)
Yang, A., Grissinger, M.: Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention. PA Patient Saf. Rep. Syst. (PA-PSRS) 10, 41–49 (2013)
Lisby, M., Nielsen, L.P., Mainz, J.: Errors in the medication process: frequency, type, and potential clinical consequences. Int. J. Qual. Health Care 17, 15–22 (2005)
Allard, J., Carthey, J., Cope, J., Pitt, M., Wood-ward, S.: Medication errors: causes, prevention and reduction. Br. J. Haematol. 116, 255–265 (2002)
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Tabibzadeh, M., Muralidharan, A. (2019). Reducing Medication Errors and Increasing Patient Safety: Utilizing the Fault Tree Analysis. In: Lightner, N. (eds) Advances in Human Factors and Ergonomics in Healthcare and Medical Devices. AHFE 2018. Advances in Intelligent Systems and Computing, vol 779. Springer, Cham. https://doi.org/10.1007/978-3-319-94373-2_23
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DOI: https://doi.org/10.1007/978-3-319-94373-2_23
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