ArticleInternational journal of clinical pharmacy2014
Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge.
Article in International journal of clinical pharmacy, 2014. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 4 papers, 1 of them a synthesis that pooled it.
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Who cites it
4 citing papers in PubMed, 1 synthesis or guideline pooled it, 12 citations in OpenAlex.
- Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review.Journal of the American Medical Informatics Association : JAMIA · 2018Pooled it
- Using risk analysis to ensure patients' medication safety during hospital relocations and evacuations.European journal of hospital pharmacy : science and practice · 2021Article
- Application of failure mode and effects analysis (FMEA) to improve medication safety in the dispensing process - a study at a teaching hospital, Sri Lanka.BMC public health · 2021Article
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Authors and funding
4 authors at 2 institutions in 2 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundDischarging patients from hospital is a complex multidisciplinary process that can lead to non-compliance and medication-related problems.
objectiveTo evaluate risks of discontinuity of pharmaceutical care at paediatric hospital discharge and assess potential improvement strategies, using two complementary methods: a prospective risk analysis and a spontaneous incident reporting system.
settingGeneva University hospitals and community pharmacies.
methodsA multidisciplinary team analysed the paediatric medication discharge process applying the failure modes (FM), effects, and criticality analysis (FMECA), using ibuprofen, morphine, valganciclovir as model drugs. Over 46 months, incidents with discharge prescriptions, reported by community pharmacists, were classified according to FMECA's FM.
main outcome measuresFM, criticality indexes (CI), incidents.
resultsTwenty-four FM were identified. The highest criticality scores were given for prescribing the wrong dosage [mean criticality index (CI = 205)], early treatment discontinuation by the patient (CI = 195), and continuation of contraindicated treatment by the general practitioner (CI = 191). Implementation of eight improvement strategies covering the eight most critical FM led to a 64 % reduction in criticality scores (CI 496 vs 1,392). Improvement of the computerized-physician-order-entry system was the single most effective strategy (CI 843 vs 1,392). Only 52 incidents were spontaneously reported (17 for paediatric patients). Paediatric problems most frequently reported (lack of information, 35 %; delay in drug supply, 18 %) were consistent with the highest frequencies scored by FMECA.
conclusionSpontaneous incident reporting leads to high levels of under-reporting, but highlighted similar problems at paediatric hospital discharge to FMECA. Using FMECA allowed estimations of criticalities at each step and the potential impact of safety improvement strategies. Proactive and reactive methods proved complementary and would help to set up effective targeted improvement strategies to improve medication process at paediatric hospital discharge.
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