FAILURE MODE AND EFFECTS ANALYSIS (FMEA): INTRAVENOUS CHEMOTHERAPY ADMINISTRATION

2.50
Hdl Handle:
http://hdl.handle.net/10755/164894
Category:
Abstract
Type:
Presentation
Title:
FAILURE MODE AND EFFECTS ANALYSIS (FMEA): INTRAVENOUS CHEMOTHERAPY ADMINISTRATION
Author(s):
Vannice, Sandra; Wimmer, Peggy
Author Details:
Sandra Vannice, RN MSN OCN AOCN, Oncology Clinical Nurse Specialist, Denver Health Medical Center, Denver, Colorado, USA, email: sbvannice@comcast.net; Peggy Wimmer, PharmD
Abstract:
A chemotherapy medication error can have a catastrophic outcome for a patient and family. System problems such as understaffing and poor communication can contribute to the occurrence of medication errors. Health care Failure Modes and Effects Analysis (FMEA) is a proactive assessment that identifies and improves steps in a process ensuring a safe and clinically desirable outcome. FMEA provides the framework for a systematic approach to identify and prevent problems before they occur. Because of the high risk related to administration of chemotherapy and the relatively small volume of patients treated at both our infusion center and hospital we chose to conduct an FMEA to ensure the highest level of safety for our cancer patients receiving chemotherapy. The purpose of this project was to evaluate our processes related to chemotherapy administration from the written order to drug delivery to ensure a high quality of patient safety A multidisciplinary team consisting of pharmacy, in patient and outpatient nursing staff, nursing administration, oncology physicians, clinic and hospital admissions staff, and risk management met to discuss processes and complete flow diagrams of chemotherapy administration to proactively determine where failures in the process could occur. A hazard analysis was conducted and interventions leading to revised policy and procedures were designed to prevent errors and improve hazards. Indicators were identified to follow outcomes and to test and analyze the redesign process. A strategy was implemented for sustaining improvements over time. The number of reportable chemotherapy events declined over time and the hazard score improved. As a result of this project the FMEA was extended to review the ordering and administration processes of cytotoxic drugs for non-oncologic indications in all settings across the institution. By reviewing the chemotherapy administration processes through an FMEA, oncology nurses are able to identify how and where failure may occur in a system leading to chemotherapy medication errors and undesired outcomes. We have improved the chemotherapy administration practices, decreased reportable events and improved the safety of chemotherapy administration to patients at our institution through the FMEA process.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2007
Conference Name:
32nd Annual Oncology Nursing Society Congress
Conference Host:
Oncology Nursing Society
Conference Location:
Las Vegas, Nevada, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleFAILURE MODE AND EFFECTS ANALYSIS (FMEA): INTRAVENOUS CHEMOTHERAPY ADMINISTRATIONen_GB
dc.contributor.authorVannice, Sandraen_US
dc.contributor.authorWimmer, Peggyen_US
dc.author.detailsSandra Vannice, RN MSN OCN AOCN, Oncology Clinical Nurse Specialist, Denver Health Medical Center, Denver, Colorado, USA, email: sbvannice@comcast.net; Peggy Wimmer, PharmDen_US
dc.identifier.urihttp://hdl.handle.net/10755/164894-
dc.description.abstractA chemotherapy medication error can have a catastrophic outcome for a patient and family. System problems such as understaffing and poor communication can contribute to the occurrence of medication errors. Health care Failure Modes and Effects Analysis (FMEA) is a proactive assessment that identifies and improves steps in a process ensuring a safe and clinically desirable outcome. FMEA provides the framework for a systematic approach to identify and prevent problems before they occur. Because of the high risk related to administration of chemotherapy and the relatively small volume of patients treated at both our infusion center and hospital we chose to conduct an FMEA to ensure the highest level of safety for our cancer patients receiving chemotherapy. The purpose of this project was to evaluate our processes related to chemotherapy administration from the written order to drug delivery to ensure a high quality of patient safety A multidisciplinary team consisting of pharmacy, in patient and outpatient nursing staff, nursing administration, oncology physicians, clinic and hospital admissions staff, and risk management met to discuss processes and complete flow diagrams of chemotherapy administration to proactively determine where failures in the process could occur. A hazard analysis was conducted and interventions leading to revised policy and procedures were designed to prevent errors and improve hazards. Indicators were identified to follow outcomes and to test and analyze the redesign process. A strategy was implemented for sustaining improvements over time. The number of reportable chemotherapy events declined over time and the hazard score improved. As a result of this project the FMEA was extended to review the ordering and administration processes of cytotoxic drugs for non-oncologic indications in all settings across the institution. By reviewing the chemotherapy administration processes through an FMEA, oncology nurses are able to identify how and where failure may occur in a system leading to chemotherapy medication errors and undesired outcomes. We have improved the chemotherapy administration practices, decreased reportable events and improved the safety of chemotherapy administration to patients at our institution through the FMEA process.en_GB
dc.date.available2011-10-27T12:08:52Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T12:08:52Z-
dc.conference.date2007en_US
dc.conference.name32nd Annual Oncology Nursing Society Congressen_US
dc.conference.hostOncology Nursing Societyen_US
dc.conference.locationLas Vegas, Nevada, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.-
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