PMID- 31622454
OWN - NLM
STAT- PubMed-not-MEDLINE
LR  - 20210607
IS  - 1535-2900 (Electronic)
IS  - 1079-2082 (Linking)
VI  - 76
IP  - 23
DP  - 2019 Nov 13
TI  - Failure mode and effects analysis to reduce risk of heparin use.
PG  - 1972-1979
LID - 10.1093/ajhp/zxz229 [doi]
AB  - PURPOSE: Failure mode and effects analysis (FMEA) was used to identify safety 
      risks of unfractionated heparin (UFH) use and to develop and implement 
      countermeasures to improve safety. METHODS: FMEA was used to analyze the 
      transportation, preparation, dispensation, administration, therapeutic 
      monitoring, and disposal of UFH in a tertiary care, freestanding pediatric 
      hospital. The FMEA was conducted in a stepwise fashion. First, frontline staff 
      mapped the different steps within the UFH use process. Next, key stakeholders 
      identified potential failures of each process step. Finally, using calibrated 
      scales, the stakeholders ranked the likelihood of occurrence, severity, and 
      detectability for each potential failure's cause. The rankings were used to 
      prioritize high-risk areas on which to focus efforts for improvement 
      countermeasures. RESULTS: The analysis revealed 233 potential failures and 737 
      unique potential causes. After ranking of all identified potential causes, 45 
      were deemed high scoring. Those 45 causes were further refined into 13 underlying 
      contributing causes. To address the contributing causes, selected team members 
      developed 22 countermeasures. The FMEA showed that implementation of the 
      countermeasures reduced the level of mathematical risk. CONCLUSION: FMEA was 
      helpful in identifying, ranking, and prioritizing medication risks in the UFH use 
      process. Twenty-two countermeasures were developed to reduce potential for error 
      in the riskiest steps of the process.
CI  - (c) American Society of Health-System Pharmacists 2019. All rights reserved. For 
      permissions, please e-mail: journals.permissions@oup.com.
FAU - Pino, Felicity A
AU  - Pino FA
AD  - Children's Mercy, Kansas City, MO, and Assistant Professor, School of Medicine 
      and Bloch School of Management, University of Missouri-Kansas City, Kansas City, 
      MO.
FAU - Weidemann, Darcy K
AU  - Weidemann DK
AD  - Children's Mercy, Kansas City, MO, and University of Missouri-Kansas City, Kansas 
      City, MO.
FAU - Schroeder, Lisa L
AU  - Schroeder LL
AD  - Medical Administration, Children's Mercy, Kansas City, MO, and University of 
      Missouri-Kansas City, Kansas City, MO.
FAU - Pabst, Damon B
AU  - Pabst DB
AD  - Pharmacy Department, Children's Mercy, Kansas City, MO, and School of Pharmacy, 
      University of Missouri, Kansas City, MO.
FAU - Kennedy, Audrey R
AU  - Kennedy AR
AD  - Clinical Safety Department, Children's Mercy, Kansas City, MO, and School of 
      Pharmacy, University of Kansas, Lawrence, KS.
LA  - eng
PT  - Journal Article
PL  - England
TA  - Am J Health Syst Pharm
JT  - American journal of health-system pharmacy : AJHP : official journal of the 
      American Society of Health-System Pharmacists
JID - 9503023
SB  - IM
OTO - NOTNLM
OT  - FMEA
OT  - failure
OT  - heparin
OT  - risk
EDAT- 2019/10/18 06:00
MHDA- 2019/10/18 06:01
CRDT- 2019/10/18 06:00
PHST- 2019/10/18 06:00 [pubmed]
PHST- 2019/10/18 06:01 [medline]
PHST- 2019/10/18 06:00 [entrez]
AID - 5589165 [pii]
AID - 10.1093/ajhp/zxz229 [doi]
PST - ppublish
SO  - Am J Health Syst Pharm. 2019 Nov 13;76(23):1972-1979. doi: 10.1093/ajhp/zxz229.