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WAYNE ADACHI, PHARM.D., is Director of Pharmacy and Diagnostic Imaging, Good Samaritan Hospital, San Jose, CA. AMY E. LODOLCE, PHARM.D., BCPS, is Clinical Assistant Professor and Drug Information Specialist, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago.

Address correspondence to Dr. Lodolce at the College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street (MC 886), Chicago, IL 60612-7230 (aelo{at}uic.edu).

Purpose. Failure mode and effects analysis (FMEA) was used to identify dosing and administration errors associated with i.v. medications and evaluate the effectiveness of subsequent system improvements. Summary. A multidisciplinary medication safety team conducted an FMEA to identify and reduce common medication errors and selected wrong-dose errors for process improvement. In 2002, wrong-dose errors comprised 17% of all medication errors at the hospital (59 of 347 errors). The most common reason for administering the wrong dose was error in programming the i.v. infusion pump (41%). Potential errors (i.e., failures) identified were misinterpretation of the order, removing the wrong medication or wrong concentration of the correct medication, using the wrong diluent or drug to prepare the drip, and entering the wrong concentration or infusion rate on the pump. Errors in programming the i.v. infusion pump was the step in the medication-use process associated with the highest criticality index. Based on the results of the FMEA, two main interventions were performed. First, standard order sets were revised after streamlining the formulary and eliminating the use of unapproved abbreviations. Second, an i.v. pump with enhanced safety features was implemented. One-year follow-up data revealed that the number of medication errors related to dosing (wrong dose or incorrect infusion rate) had decreased slightly (from 59 in 2002 to 46 in 2003); however, a dramatic reduction was noted in the percentage of pump-related errors. In 2003, pump-related errors accounted for 22% of dosing errors, compared with 41% in 2002. Conclusion. Medication errors related to i.v. infusion pumps were reduced by conducting an FMEA and implementing the process changes needed. Index terms: Abbreviations; Devices; Diluents; Dosage; Drug administration rate; Errors, medication; Formularies; Hospitals; Injections; Medication orders; Methodology; Toxicity

 

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