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PS-064 Impact of remedial actions after a risk analysis by a failure mode effects and consequences analysis on pharmaceutical interventions in a paediatric hospital
  1. E Jouhanneau1,
  2. A Fratta1,
  3. A Auvrignon2,
  4. J Descout1
  1. 1Hôpital Trousseau, Pharmacy, Paris, France
  2. 2Hôpital Trousseau, Haematology, Paris, France


Background Paediatric patients are more subject to medication errors. Since 2015, pharmaceutical interventions (PI) are gathered during the pharmacist validation process on a daily basis. During the first 2 months (P1) of the study, we observed 212 PI out of 2354 prescriptions (9%). The failure mode effects and consequences analysis (FMECA) was used. The severity (S), frequency (F) and response time (T) of these PI were scored by a multidisciplinary team (physician, pharmacists). A critical score was calculated by C=S×F×T. In a Deming wheel approach, 7 remedial actions were implemented. The same study was carried out in a 2 months period in 2016 (P2).

Purpose The aim of this study was to compare P1 and P2 to measure the impact of our remedial actions.

Material and methods PI were gathered on Genois software. The data analysis was performed in Excel. The results were compared using a χ2 test.

Results During P2, we observed 151 PI out of 2608 prescriptions (5.8%). The rate of PI during P2 was significantly lower than during P1 (p<0.05). The ATC distribution was the same. The most represented drug classes were GI tract drugs, nervous system drugs and anti-infective drugs, respectively. The most frequent problems were the same between P1 and P2. Wrong dosage represented 65% in P1 and 57% in P2 of PI, respectively. No significant difference was observed between P1 and P2 for PI outcomes. Of 212 PI (P1), 46.3% were accepted (49% during P2), 19.8% were not accepted (10.6% during P2) and 34% were unanswered (40.4% during P2). The insufficient number of pharmacists in medical units could explain the low rate of accepted PI. The severity and frequency of PI were significantly reduced (p<0.05) between P1 and P2. Criticality of PI did not change. This could perhaps be explained by the fact that all high critical PI were due to high response time.

Conclusion With FMECA and our remedial actions, the number of PI, their severity and frequency were decreased. To enhance our prescription validation process, several actions must again be undertaken to improve the acceptation rate and to decrease response time.

No conflict of interest

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