Risk Analysis of Intravenous Drug Administration Process to Patients in a Brazilian Hospital

Tuesday, 14 July 2009

Ana Elisa Bauer de Camargo Silva, RN, PhD
Nursing Department, Faculty of Nursing of Federal University of Goias, Goiânia, Brazil
Silvia H. De Bortoli Cassiani, RN, PhD
Nursing Generality and Specialized Department, University of São Paulo at Ribeirão Preto, College of Nursing, Ribeirao Preto, Brazil

Learning Objective 1: identify the potential risks, failure potential modes, effects and causes in intravenous anti-infectious drug ministration in Brazilian hospital.

Learning Objective 2: identify the severity and most frequent types of failure potential effects of intravenous anti-infectious drug ministration in Brazilian hospital.

Purpose: This exploratory study has analysed potential risks associated to intravenous anti-infectious drug administration process.

Methods: It was conducted at the university hospital in Goiás, Central-West of Brazil, by Failure Modes and Effects Analysis method. For data collection was formed a multidisciplinary staff: risk and nurse manager, medical, nurse, pharmacist and searcher.

Results: Results showed that administration process involves 4 micro process, 10 activities, 22 functions. The search identified 52 failure potential modes (FPM) whose most significant frequencies happened in the drug administration (30.8%); drug preparation (23.1%); drug delay (9,6%) and drug names transcription to tags (9.6%). The study identified also 79 failure potential effects (FPE). Among FPE, 36.2% were considered as of medium severity; 28.7% moderate severity, and 27.5% of high severity. High severity effects were identified in 80% of the activities. Effect classification pointed that the most frequent types were the following ones: technical (26.6%), omission (25.3%), schedule (19%). A number of 285 failure potential causes (FPC) were identified with the following occurrence rates: 91 (31.9%) medium, 78 (27.4%), low or extremely low; 40 (14.0%), high; and 30 (10.5%), extremely high. FPC were classified in three categories: organizational process management (43.9%); human resources (41.4%); physical and material structure (12.6%). Concerning to control types, results showed 92.9% derived from detection and 5.3% were prevention ones. FPC Risk priority number (RPN) calculation showed that 20.7% had high-risk priority; 54.7% medium and 24.6% low-risk priority. A number of 298 recommendations were done to high and medium priority FPC: 81.9% short term, 13.4% de medium term and 4.7% de long-term ones.

Conclusion: Action impact simulation on failure modes allowed to identify a 79.7% reduction in high priority FPM as well a 59.6% one in high criticality FPM ones by means of simple and quick application measures that can improve reliability and safety in drug administration process.