Prospective risk analysis of the anti-infective medication administration process

Rev Lat Am Enfermagem. 2013 Jan-Feb:21 Spec No:233-41. doi: 10.1590/s0104-11692013000700029.
[Article in English, Portuguese]

Abstract

Objective: The objective of this study was to analyze the potential risks involved in the administration process of intravenous anti-infective medication at a medical clinic, using the Failure Mode and Effect Analysis.

Method: This exploratory study was conducted at the medical clinic of a hospital in the State of Goiás. For data collection we convened a team comprised of six professionals involved in medication treatment: a doctor, nurse, nursing technician, pharmacist, a nursing and a risk manager. A total of 24 meetings were held, for a total of 56 hours. The data were transcribed into an electronic database within Microsoft Excel®, and the Xfmea4 software was used.

Result: The results indicated 52 failure modes, 79 effects of failure, and 285 causes of failure. The causes were related to: the management of organizational processes, human resources, physical and material structure. A total of 298 actions for improvement were recommended for 215 causes of high and average priority, 81.9% of which were short-term priorities. The simulation of the impact of the proposed interventions revealed a 79.7% reduction of the high-priority failure modes.

Conclusion: It was concluded that the study identified potential risks to patients and recommended proactive actions, of rapid application and low cost, evaluated positively in the reduction of risk of occurrence of avoidable incidents, increasing reliability and safety of the medication administration process. Studies like this demonstrate that, with the application of a method of risk analysis, nurses can effectively assist in preventing medication incidents.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anti-Infective Agents / administration & dosage*
  • Humans
  • Infusions, Intravenous / adverse effects
  • Prospective Studies
  • Risk Assessment*

Substances

  • Anti-Infective Agents