Objectives: to identify, classify, and analyze modes of failure in the medication process.
Methods: evaluative research that used the Healthcare Failure Mode and Effect Analysis (HFMEA) in a service of bone marrow transplant from June to September 2018, with the participation of 35 health workers.
Results: 207 modes of failure were identified and classified as mistakes in verification (14%), scheduling (25.6%), administration (29%), dilution (16.4%), prescription (2.4%), and identification (12.6%). The analysis of risk showed a moderate (51.7%) and high (30.9%) need of intervention, leading to the creation of an internal quality assurance group and of continued education activities.
Conclusions: the Healthcare Failure Mode and Effect Analysis showed itself to be a tool to actively identify, classify, and analyze failures in the process of medication, contributing for the proposal of actions aimed at patient safety.
Download full-text PDF |
Source |
|---|---|
| http://dx.doi.org/10.1590/0034-7167-2021-0153 | DOI Listing |
Publication Analysis
Top Keywords
Similar Publications
A mixed-methods observational study of strategies for success in implementation science: overcoming emergency departments hurdles.
BMC Health Serv Res
January 2025
Emergency Medicine, Vanderbilt University Medical Center and, Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.
Background: Heart failure is a major public health concern, affecting 6.7 million Americans. An estimated 16% of emergency department (ED) patients with acute heart failure (AHF) are discharged home.
View Article and Find Full Text PDF[SELENON-related myopathy with scoliosis and respiratory failure since early childhood diagnosed through reassessment during pediatric-to-adult healthcare transition: a case report].
Rinsho Shinkeigaku
January 2025
Department of Neurology, The University of Tokyo Hospital.
The patient was a 33-year-old woman with no family history of a similar disorder. At one year of age, she exhibited scoliosis and respiratory failure, necessitating a tracheostomy performed at 5 years of age (1990s). During that time, the patient was provisionally diagnosed with "non-Fukuyama congenital muscular dystrophy" via muscle biopsy.
View Article and Find Full Text PDFBenefits of Duplex Ultrasound Surveillance of infra-inguinal bypass grafts and institutional costs of graft failure: a retrospective single-centre study.
Ann Vasc Surg
January 2025
The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, LS1 3EX, UK. Electronic address:
Objective: The Achilles' heel of infrainguinal bypass grafts (IIBG) is restenosis. Duplex ultrasound (DUS) surveillance is commonly undertaken to identify restenosis allowing intervention for graft salvage. We report the impact of DUS surveillance on patient outcomes alongside healthcare-associated costs.
View Article and Find Full Text PDFExploring Haemodialysis Nurses' Perceptions on Kidney Replacement Therapy Modality Education: A Framework Analysis.
J Ren Care
March 2025
Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada.
Background: Many people with kidney failure start and remain on in-centre haemodialysis treatment despite evidence of improved outcomes with home dialysis. To make an informed modality decision patients must receive frequent, high-quality modality education. This education is inconsistent in the in-centre haemodialysis setting, where patients spend the most time with nurses while receiving haemodialysis treatments.
View Article and Find Full Text PDFDifferences between private and public primary health care centers and differences between men and women in antihypertensive care and cardiovascular prevention in all patients with hypertension treated in primary care in Stockholm County, Sweden.
BMC Prim Care
January 2025
Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
Aims: To study differences in cardiovascular prevention and hypertension management in primary care in men and women, with comparisons between public and privately operated primary health care (PHC).
Methods: We used register data from Region Stockholm on collected prescribed medication and registered diagnoses, to identify patients aged 30 years and above with hypertension. Age-adjusted logistic regression was used to calculate odds ratios (ORs) with 99% confidence intervals (99% CIs) using public PHC centers as referents.
Want AI Summaries of new PubMed Abstracts delivered to your In-box?
Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!