Failure mode and effects analysis: a novel approach to avoiding dangerous medication errors and accidents.
It is time that hospitals realize that human error is inevitable and must be anticipated. A technique developed in the aerospace industry and known as "failure mode and effects analysis" involves identifying mistakes that will happen before they happen, and determining whether the consequences of those mistakes would be tolerable or intolerable. This article shows how this practice can be adapted to a hospital environment by using a continuous quality improvement approach. Examples show how actual fatal errors can be prevented.
Institute for Safe Medication Practices, Huntingdon Valley, PA 19006.
M R
MR
Cohen
J
J
Senders
N M
NM
Davis
D000056:Accident Prevention; D004282:Documentation; D004348:Drug Labeling; D004349:Drug Packaging; D006801:Humans; D015274:Interdepartmental Relations; D008508:Medication Errors; D008510:Medication Systems, Hospital / Q000592:standards*; D009738:Nursing Service, Hospital / Q000592:standards; D010607:Pharmacy Service, Hospital / Q000592:standards; D017751:Safety Management / Q000379:methods*; D017749:Total Quality Management; D014481:United States