A PROACTIVE RISK MANAGEMENT USING FAILURE MODE AND EFFECTS ANALYSIS FOR INFUSION THERAPY IN A TERTIARY HOSPITAL INTENSIVE CARE UNIT IN EGYPT

Aims: to apply a Failure Mode & Effects Analysis (FMEA) for infusion therapy in Ain Shams University hospital ICU for the ultimate purpose of proactively averting risks associated with such therapy. Materials and methods: A multidisciplinary FMEA team was formed. The team started by drawing a detailed flow chart of the infusion process and identified the potential failure modes. After listing effects of each failure mode, the severity, occurrence and detection ability were given scores resulting in a risk priority number (RPN). A Pareto analysis was used to prioritize the different failure modes according to their RPN. Improvement actions were suggested and implemented for the selected failure modes. Evaluation of the intervention was performed by re-calculating the RPN, satisfaction survey for the medical staff in the Intensive care unit (ICU) and measuring medication errors pre and post intervention. Results: A total of 11 failure modes with highest RPN scores including bringing wrong medication during preparation, wrong documentation and administration of the wrong medication were selected for improvement. The implemented improvements included designing new medication sheet, training, proper labeling of drugs to avoid the look alike medication, correctly identifying the patients, policy to avoid transcription, double checking in some steps of the process as well as some changes in the maintenance system. Overall, the improvements carried out were satisfying the medical staff of the unit, reduced the pre-intervention RPN and medication errors. Conclusion: Application of the FMEA in the ICU proved to be effective in proactively correcting potential failures in the infusion process and has impact on medical staff satisfaction.