Aplicación de un análisis modal de fallos y efectos para la mejora de la seguridad en la utilización de los sistemas automatizados de dispensación de medicamentos

Abstract

ObjectiveTo identify the risks in automated dispensing cabinet use in order to improve routine procedure safety. MethodsWe used the Failure Mode Effect Analysis (FMEA) methodology. A multidisciplinary team identified potential failure modes of the procedure through a brainstorming session. We assessed the impact associated with each failure mode with the Risk Priority Number (RPN), which involves three variables: occurrence, severity, and detectability. Improvement measures were established for failure modes with RPN>100 considered critical. The final RPN (theoretical) that would result from the proposed measures was also calculated. ResultsThe process was divided into five sub-processes: automatic delivery of order replacement, to prepare order in a pyramidal cart, transport of the pyramidal cart from the pharmacy service to the automated dispensing cabinet, replacement of the automated dispensing cabinet by the pharmacy technician and dispensing/returning by nursing staff. Twenty-two failure modes, with 25 cases and with varying effects (severity 2-8) were evaluated. The sub-process with more failure modes with NPR>100 was dispensing/returning by nursing staff. ConclusionsThe FMEA methodology was a useful tool when applied to automated dispensing cabinet system use. The implementation of improvement actions significantly reduced the risk.