Background Errors in drug treatment are the leading cause of injury in hospitalised patients. According to international studies, medicines errors are multifactorial and involve various health professionals.
Purpose To improve the flow of prescriptions in the surgical area, introducing more checking steps and reducing errors by using FMEA (Failure Mode and Effect Analysis), a proactive approach to risk management.
Materials and methods The project involved 8 departments in the surgical area (Abdominal Pelvic Surgery, Breast Care, Anaesthesia and Intensive Care, Thoracic Surgery, Reconstructive Surgery, General Surgery, Head and Neck Surgery, Gynaecology). Each department participated in interdisciplinary teams (doctors, nurses, pharmacists), in collaboration with Quality and Risk Management Services. The eight teams developed the project through participation in classroom training and practical exercises. The project was broken down into several stages: detailed analysis of the pharmacological process in all the individual activities; assessment by a risk index; definition of containment plans; monitoring of the efficacy of containment plans. Process analysis and risk mapping highlighted that that the priority risks identified are more related to the stages of transcription and communication within the department.
Results A total of 49 priority risks were identified, and each division developed an average of 3 independent containment plans, which led to some changes of activity in the pharmacological process. The overall risk index has been reduced by 13.5%, while the impact on priority risks led to a reduction of the value of risk indexes by 26%.
Conclusions At the end of the first monitoring phase, results were presented to all departments in a plenary session. Risk indexes calculated to date are approximate and represent a partial result that should be confirmed at the end of containment plans. These first encouraging results are almost entirely due to a multidisciplinary approach, taking charge of only priority risks, and succeeding in significantly improving communication.
No conflict of interest.
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