Challenges with applying FMEA to the process for reading labels on injectable drug containers

Proceedings of the Human Factors and Ergonomics Society

Volumn 2, Issue , 2007, Pages 735-739

  Jeon, Jennifer ^a   Hyland, Sylvia ^b   Burns, Catherine M ^a   Momtahan, Kathryn ^c  

^a UNIVERSITY OF WATERLOO   (Canada)

^b Institut pour l'utilisation securitaire des medicaments du Canada   (Canada)

^c UNIVERSITY OF OTTAWA   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

CRITICALITY (NUCLEAR FISSION); ERGONOMICS; HUMAN ENGINEERING; LABELS; QUALITY ASSURANCE; RELIABILITY ANALYSIS; SAFETY FACTOR;

COGNITIVE PROCESSES; FOCUS GROUPS; HEALTHCARE PROFESSIONALS; RATING SCALES;

FAILURE ANALYSIS;

EID: 58149458669     PISSN: 10711813     EISSN: None     Source Type: Conference Proceeding    
DOI: None     Document Type: Conference Paper

References (17)

1. Bonnabry, P., Cingria, L., Sadeghipour, F., Ing, H., Fonzo-Christe, C, & Pfister, R. E. (2005). Use of a systematic risk analysis method to improve safety in the production of paediatric parenteral nutrition solutions. Qual Saf Health Care, 14(2), 93-98.
2. Burgmeier, J. (2002). Failure mode and effect analysis: an application in reducing risk in blood transfusion. Jt Comm J Qual Improv, 28(6), 331- 339.
3. CSA International. (1999). Labelling of Drag Ampoules, Vials, and Prefilled Syringes (Vol. CAN/CSAZ-264.2). Etobicoke, Ontario, Canada: CSA International.
4. DeRosier, J., Stalhandske, E., Bagian, J. P., & Nudell, T. (2002). Using Health Care Failure Mode and Effect Analysis& trade;: The VA National Center for Patient Safety's Prospective Risk Analysis System. Joint Commission Journal on Quality and Patient Safety, 28(5), 248-267.
5. Esmail, R., Cummings, C, Dersch, D., Duchscherer, G., Glowa, J., Liggett, G., & Hulme, T. (2005). Using Healthcare Failure Mode and Effect Analysis tool to review the process of ordering and administrating potassium chloride and potassium phosphate. Healthc Q, 8 Spec No, 73-80.
6. Fechter, R. J., & Barba, J. J. (2004). Failure mode effect analysis applied to the use of infusion pumps, San Francisco, CA, United States.
7. Hicks, R. W., Santell, J. P., Cousins, D. D., & Williams, R. L. (2004). MEDMARX5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999-2003. Rockville, MD: USP Center for the Advancement of Patient Safety.
8. Institute for Safe Medication Practices Canada. (2006). Failure Mode and Effects Analysis - A tool for proactively identifying risk in health care (pp. 26): Institute for Safe Medication Practices Canada.
9. Krouwer, J. S. (2004). An improved failure mode effects analysis for hospitals. Arch Pathol Lab Med, 128(6), 663-667.
10. Leape, L. L., Brennan, T. A., Laird, N., Lawthers, A. G., Localio, A. R., Barnes, B. A., Hebert, L., Newhouse, J. P., Weiler, P. C, & Hiatt, H. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. NEngl J Med, 324(6), 377-384.
11. National Coordinating Council for Medication Error Reporting and Prevention. (2001). NCC MERP Index for Categorizing Medication Errors. Retrieved Nov. 26, 2006, from http://www.nccmerp.org/medErrorCatIndex.html
12. Rich, D. S. (2001,). Complying with the FMEA Requirements of the New Patient Safety Standards. Retrieved November 28, 2006, from www.fmeainfocentre. com/presentations/fmea-requirements.ppt
13. Senders, J. W. (2004). FMEA and RCA: the mantras; of modern risk management. Qual Saf Health Care, 13(4), 249-250.
14. United States Pharmacopoeia. (1998). USP/FDA Panel Recommends Improved and Uncrowded Injection Labels [Electronic Version]. USP Quality Review, 62. Retrieved February 12, 2007 from http://www.usp.org/patientSafety/ newsletters/qualityReview/qr62I998-05-01b.html.
15. United States Pharmacopoeia. (2000). DPPR-a Final Glance (No. 75): United States Pharmacopeia.
16. Wetterneck, T. B., Skibinski, K., Schroeder, M., Roberts, T. L., & Carayon, P. (2004). Challenges with the Performance of Failure Mode and Effects Analysis in Healthcare Organizations: An IV Medication Administration HFMEA. Paper presented at the Human Factors and Ergonomics Society 48th Annual Meeting, New Orleans, Louisiana.
17. Zapanta, C. M., Snyder, A. J., Weiss, W. J., Cleary, T. J., Reibson, J. D., Rawhouser, M. A., Lewis, J. P., Pierce, W. S., & Rosenberg, G. (2005). Durability testing of a completely implantable electric total artificial heart. Asaio J, 51(3), 214-223.