Abstract
to identify, classify, and analyze modes of failure in the medication process. evaluative research that used the Healthcare Failure Mode and Effect Analysis (HFMEA) in a service of bone marrow transplant from June to September 2018, with the participation of 35 health workers. 207 modes of failure were identified and classified as mistakes in verification (14%), scheduling (25.6%), administration (29%), dilution (16.4%), prescription (2.4%), and identification (12.6%). The analysis of risk showed a moderate (51.7%) and high (30.9%) need of intervention, leading to the creation of an internal quality assurance group and of continued education activities. the Healthcare Failure Mode and Effect Analysis showed itself to be a tool to actively identify, classify, and analyze failures in the process of medication, contributing for the proposal of actions aimed at patient safety.
Highlights
Design, period, and place of studyConsidering the complexity of the procedures and treatments in the services that provide health care, there is a real possibility of harm to the patient[1]
The Healthcare Failure Mode and Effect Analysis (HFMEA) was shown to be a tool that can be used by the group responsible for the medication process, enabling the identification of failures and allowing this group to take the main role in the planning of corrective and preventive actions, basing them on their professional experiences
We found that the Risk Priority Number (RPN) values were from moderate (51.7%) to high (30.9%)
Summary
Considering the complexity of the procedures and treatments in the services that provide health care, there is a real possibility of harm to the patient[1]. This risk requires actions to promote safe care through the identification of potential failures and the search for solutions, such as the use of protocols that standardize and guide professional practice. Known as“bone marrow transplant”, this is one of the main treatments for patients with oncological, hematological, and congenital diseases This modality of care makes it possible to extend the period of life and may even represent a cure, by replacing the diseased or deficient bone marrow with healthy hematopoietic stem cells[2]. This research is justified by the relevance of continuously monitoring the risks and the evaluation of this protocol, which has been used since April 2018, and the importance of identifying failures and making potential changes, planning new topics, and taking corrective and preventive action
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