Publication: Aplicación de un análisis modal de fallos y efectos para la mejora en la seguridad de la utilización de los sistemas automatizados de dispensación de medicamentos
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2018-02-20
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Universidad Complutense de Madrid
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Abstract
El interés por disminuir los riesgos asociados a la asistencia sanitaria ha llevado a numerosas organizaciones internacionales y nacionales, a establecer estrategias y recomendaciones para que las instituciones dispongan de sistemas que mejoren la calidad, la seguridad y la eficiencia de la atención a los pacientes. La utilización de los medicamentos es un proceso clave dentro del sistema sanitario, en el que pueden producirse errores, tal como se ha descrito en numerosos estudios durante las últimas décadas. El Análisis Modal de Fallos y Efectos (AMFE) es una herramienta de seguridad que tiene un impacto favorable en el entorno asistencial del paciente(1). Es un método de análisis prospectivo y sistemático que permite identificar situaciones en las que un proceso o el diseño de un proceso pueden fallar, por qué pueden fallar, valorar los efectos de errores potenciales y priorizar medidas correctoras. El AMFE consta de 5 pasos y se realiza por un equipo multidisciplinar. Éste elabora un diagrama de flujo del proceso, a partir del cual se identifican los posibles fallos que pueden producirse en cada etapa (modos de fallo) y, con una matriz de riesgo (Hazard Score), se priorizan las acciones que deben implantarse, para evitar que se produzcan los mismos. Es adecuado para analizar el proceso de utilización de los medicamentos(1-3). De hecho, es una herramienta recomendada por el ISMP(4). Se han publicado estudios que lo utilizan para reducir los errores de medicación(5), mejorar la seguridad en la elaboración de la nutrición parenteral(6) y fórmulas magistrales, identificar los riesgos del sistema de distribución de medicamentos en dosis unitarias(7, 8) y la administración de medicamentos en general(9) , y específicamente de la quimioterapia(10-15)...
The aim to reduce the risks associated to the healthcare has lead to many national and international organizations to set strategies and recommendations so the institutions are provided with systems that would enhace the patient care quality, security and efficiency. As described in many studies during the last decades, the use of drugs is a key process within the health system, in which errors may occur. The Failure Modes and Effects Analysis (FMEA) is a security tool with a positive impact in the patient care setting(1). Is a prospective and systematic method that allows to identify situations where a process or a process design can fail, the reason of the failure, assess the effects of potential errors and prioritize corrective measures. The FMEA consists on 5 steps and is performed by a multidiciplinar team. This team, designs a diagram process flow where the potential failures in each step will be identified (failure modes) and in order to prevent them from occuring, actions to be implemented are prioritized with a hazard score. It is suitable for analyzing the process of medicines use(1-3). In fact, it is a tool recommended by the ISMP(4). Several studies have been published where it is used to reduce medication erros(5), improve the safety in parenteral nutritions(6) and compounding, identify the unit dose distribution system risks(7, 8), and the drug administration in general, and specifically chemotherapy(10-15)...
The aim to reduce the risks associated to the healthcare has lead to many national and international organizations to set strategies and recommendations so the institutions are provided with systems that would enhace the patient care quality, security and efficiency. As described in many studies during the last decades, the use of drugs is a key process within the health system, in which errors may occur. The Failure Modes and Effects Analysis (FMEA) is a security tool with a positive impact in the patient care setting(1). Is a prospective and systematic method that allows to identify situations where a process or a process design can fail, the reason of the failure, assess the effects of potential errors and prioritize corrective measures. The FMEA consists on 5 steps and is performed by a multidiciplinar team. This team, designs a diagram process flow where the potential failures in each step will be identified (failure modes) and in order to prevent them from occuring, actions to be implemented are prioritized with a hazard score. It is suitable for analyzing the process of medicines use(1-3). In fact, it is a tool recommended by the ISMP(4). Several studies have been published where it is used to reduce medication erros(5), improve the safety in parenteral nutritions(6) and compounding, identify the unit dose distribution system risks(7, 8), and the drug administration in general, and specifically chemotherapy(10-15)...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Farmacia, Departamento de Farmacología, leída el 08-06-2017