Risk assessment of look‒alike, sound‒alike (LASA) medication errors in an Italian hospital pharmacy: A model based on the ‘Failure Mode and Effect Analysis’
Journal Title: Journal of Health and Social Sciences - Year 2017, Vol 2, Issue 1
Abstract
Introduction: Look alike/sound alike (LASA) drugs errors can take place in hospital wards, and they can place patients at risk for adverse events and death. This study was aimed to realize a risk assessment model for preventing LASA drugs distribution errors by the ‘S.Giovanni di Dio e Ruggi d’Aragona’ hospital pharmacy, in Salerno, Italy. Methods: We used the ‘Failure Mode and Effect Analysis’ (FMEA) technique in combination with the Recommendations released by the Italian Ministry of Health in 2010. Our analysis led to the identification of the potential failure modes, together with their causes and effects, using the risk priority number (RPN) scoring system. A paired T test was used to compare means of RPN 1 and RPN 2, respectively before and after their application, in order to evaluate the effectiveness of corrective actions. Results: In total, 6 phases, 16 steps, and 13 different potential failure modes were identified. The highest ranked failure modes, with an RPN score of 48 pertained to wrong drug dosage selection. Some of the critical failure modes in sample processing (phases n.1, 2, 3, and 4) were improved by 69.7% in the RPN by focusing on automated technology systems. T test showed that the difference between RPN 1 and RPN 2 was statistically significant for all corrective measures provided by our action plan. Conclusions: Our study showed a lot of potential failure modes related to LASA drugs distribution system provided by the hospital pharmacy. Information technology solutions can be effective to reduce this risk, but the potential for error will remain unless these systems are carefully implemented.
Authors and Affiliations
Nestor Ciociano, Lucilla Grisi, Lucia Bagnasco, Maria Giovanna Elberti, Marcello Mazzarella
Keywords
Related Articles
- EP ID EP216266
- DOI 10.19204/2017/rsks4
- Views 90
- Downloads 0
Health inequalities, welfare state regimes and economic crisis: A comparative analysis in Sweden, Greece and Poland
Introduction: The aim of this paper is to explore individual-level determinants of health inequalities across three European countries (Sweden, Greece and Poland) with different welfare systems and differently affected b...
Prevalence and management of child sexual abuse cases presented at Nigerian hospitals: A systematic review
Introduction: Aim of this study was to review all suspected sexual abuse (SA) cases presenting at Nigerian hospitals, in order to examine both the prevalence of child sexual abuses (CSA) cases and the availability of hos...
Physicians’ and nurses’ knowledge and attitudes in management of sepsis: An Italian study
Introduction: Sepsis is one of the most deadly and costly conditions at hospitals. Our study aimed to study levels of knowledge and attitudes in management of sepsis among nurses and physicians employed at Fatebenefratel...
Tarred with the same brush: An initial inquiry into courtesy stigma and problem gambling
Introduction: This study explores the relative intensity of courtesy stigma around problem gambling to other stigmatized conditions, and the ways in which courtesy stigma (or fear thereof) impacts problem gambling. Metho...
Learning to live: The role of education policy for improving the quality of primary and preventative healthcare in the United States
From a policy standpoint, education and healthcare are often discussed separately in the United States. A review of the current literature reveals that education can be a strong predictor of individual health outcomes, i...