Applying HFMEA to prevent chemotherapy errors

Journal of Medical Systems

Volumn 36, Issue 3, 2012, Pages 1543-1551

  Cheng, Chia Hui ^a   Chou, Chia Jen ^b   Wang, Pa Chun ^a,c,d   Lin, Hsi Yen ^a   Kao, Chi Lan ^a   Su, Chao Ton ^b  

^a CATHAY GENERAL HOSPITAL   (Taiwan)

^b NATIONAL TSING HUA UNIVERSITY   (Taiwan)

^c FU JEN CATHOLIC UNIVERSITY   (Taiwan)

^d CHINA MEDICAL UNIVERSITY   (Taiwan)

Author keywords

Chemotherapy process; Computerized physician order entry; Healthcare failure mode and effect analysis (HFMEA); Risk analysis

Indexed keywords

ARTICLE; CANCER CHEMOTHERAPY; COMPUTERIZED PROVIDER ORDER ENTRY; DECISION TREE; DRUG FORMULATION; DRUG TREATMENT FAILURE; HEALTHCARE FAILURE MODE AND EFFECT ANALYSIS; HOSPITAL PATIENT; HUMAN; OUTPATIENT; PRESCRIPTION; RISK ASSESSMENT; RISK REDUCTION; THERAPEUTIC ERROR;

DRUG THERAPY; HOSPITALS, GENERAL; HUMANS; MEDICAL ORDER ENTRY SYSTEMS; MEDICATION ERRORS; PHARMACY SERVICE, HOSPITAL; RISK ASSESSMENT; TAIWAN; USER-COMPUTER INTERFACE;

EID: 84864026946     PISSN: 01485598     EISSN: 1573689X     Source Type: Journal    
DOI: 10.1007/s10916-010-9616-7     Document Type: Article

References (21)

1. Dizon, D. S., Sabbatini, P. J., Aghajanian, C., Hensley, M. L., and Spriggs, D. R., Analysis of patients with epithelial ovarian cancer of fallopian tube carcinoma retreated with cisplatin after development of a carboplatin allergy. Gynecol. Oncol. 82:378-82, 2002. (Pubitemid 34211861)
2. Sheridan-Leos, N., Schulmeister, L., and Hartranft, S., Failure mode and effect analysis: a technique to prevent chemotherapy errors. Clin. J. Oncol. Nurs. 10:393-398, 2006.
3. Schulmeister, L., Chemotherapy medication errors: description, severity, and contributing factors. Oncol. Nurs. Forum 26:1033-1042, 1999.
4. Greenall, J., Failure modes and effects analysis: a tool for identifying risk in community pharmacies. Can. Pharm. J. 140:191-193, 2007. (Pubitemid 46815009)
5. Roland, H. E., and Moriarity, B., System safety engineering and management. Wiley, Hoboken, 1990.
6. Teoh, P. C., and Case, K., An evaluation of failure modes and effect analysis generating method for conceptual design. Int. J. Comput. Integr. Manuf. 18:279-293, 2005. (Pubitemid 41673249)
7. Joint Commission on Accreditation on Healthcare Organization, Revisions to Joint Commission standards in support of patient safety and medical/health care error reduction. Joint Commission on Accreditation on Healthcare Organization, Oakbrook Terrace, 2002.
8. Hambleton, M., Applying root cause analysis and failure mode and effect analysis to our compliance programs. J. Health Care Compl. 7:5-13, 2005.
9. Kunac, D. L., and Reith, D. M., Identification of priority for medication safety in neonatal intensive care. Drug Saf. 28:251-261, 2005. (Pubitemid 40364891)
10. Voeffray, M., Pannatier, A., Stupp, R., Fucina, N., Leyvraz, S., and Wasserfallen, J. B., Effect of computerisation on the quality and safety of chemotherapy prescription. Qual. Saf. Health Care 15:418-421, 2006. (Pubitemid 46025153)
11. Markert, A., Thierry, V., Kleber, M., et al., Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment. Int. J. Cancer 124:722-820, 2009.
12. Bonnabry, P., Cingria, L., Ackermann, M., Behrens, M., and Engelhardt, M., Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int. J. Qual. Health Care 18:9-16, 2006. (Pubitemid 43174761)
13. American Society of Health-System Pharmacists, ASHP guidelines on preventing medication errors with antineoplastic agents. Am. J. Health Syst. Pharm. 59:1648-1668, 2002.
14. DeRosier, J., Stalhandske, E., Bagian, J. P., and Nudell, T., Using health care failure mode and effect analysis: the VA national center for patient safety's prospective risk analysis system. Jt. Comm. J. Qual. Improv. 28:248-267, 2002.
15. Habraken, M. M., Van der Schaaf, T. W., Leistikow, I. P., et al., Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch health care. Ergonomics 52:809-819, 2009.
16. Kimehi-Woods, J., Shultz, J. P., Leistikow, I. P., and Reijnders-Thijssen, P. M., Using HFMEA to assess potential for patient harm from tubing misconnections. Jt. Comm. J. Qual. Patient Saf. 32:373-381, 2006.
17. van Tilburg, C. M., Leistikow, I. P., Rademaker, C. M., Bierings, M. B., and van Dijk, A. T., Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward. Qual. Saf. Health Care 15:58-63, 2006.
18. Esmail, R., Cummings, C., Dersch, D., Duchscherer, G., Glowa, J., and Liggett, G., Patient safety and adverse events team. Using health care failure mode and effect analysis tool to review the process of ordering and administrating potassium chloride and potassium phosphate. Healthc. Q. 8:73-80, 2005.
19. Linkin, D. R., Sausman, C., Santos, L., Lyons, C., Fox, C., and Aumiller, L., Applicability of health care failure mode and effect analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments. Clin. Infect. Dis. 41:1014-1019, 2005. (Pubitemid 41368226)
20. Cohen, M. R., Anderson, R. W., Attilio, R. M., Green, L., Muller, R. J., and Pruemer, J. M., Preventing medication errors in cancer chemotherapy. Am. J. Health Syst. Pharm. 53:737-746, 1996. (Pubitemid 26112665)
21. Kim, G. R., Chen, A. R., Arceci, R. J., Mitchell, S. H., Kokoszka, K. M., and Daniel, D., Error reduction in pediatric chemotherapy computerized order entry and failure modes and effects analysis. Arch. Pediatr. Adolesc. Med. 160:495-498, 2006.