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.
Methods: It was conducted at the university hospital in Goiás, Central-West of
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.