title: [Failure modes and effects analysis in the prescription, validation and dispensing process].
abstract: OBJECTIVE
  To apply a failure modes and effects analysis to the prescription, validation and dispensing process for hospitalised patients.
  
  
  METHODS
  A work group analysed all of the stages included in the process from prescription to dispensing, identifying the most critical errors and establishing potential failure modes which could produce a mistake. The possible causes, their potential effects, and the existing control systems were analysed to try and stop them from developing. The Hazard Score was calculated, choosing those that were ≥ 8, and a Severity Index = 4 was selected independently of the hazard Score value. Corrective measures and an implementation plan were proposed.
  
  
  RESULTS
  A flow diagram that describes the whole process was obtained. A risk analysis was conducted of the chosen critical points, indicating: failure mode, cause, effect, severity, probability, Hazard Score, suggested preventative measure and strategy to achieve so. Failure modes chosen: Prescription on the nurse's form; progress or treatment order (paper); Prescription to incorrect patient; Transcription error by nursing staff and pharmacist; Error preparing the trolley.
  
  
  CONCLUSIONS
  By applying a failure modes and effects analysis to the prescription, validation and dispensing process, we have been able to identify critical aspects, the stages in which errors may occur and the causes. It has allowed us to analyse the effects on the safety of the process, and establish measures to prevent or reduce them.
authors.affiliation: Servicio de Farmacia, Hospital Ramón y Cajal, Madrid, España. edelgado.hrc@salud.madrid.org
authors.forename: E
authors.initials: E
authors.lastname: Delgado Silveira
authors.forename: A
authors.initials: A
authors.lastname: Alvarez Díaz
authors.forename: C
authors.initials: C
authors.lastname: Pérez Menéndez-Conde
authors.forename: J
authors.initials: J
authors.lastname: Serna Pérez
authors.forename: M A
authors.initials: MA
authors.lastname: Rodríguez Sagrado
authors.forename: T
authors.initials: T
authors.lastname: Bermejo Vicedo
mesh_terms: D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D055695:Electronic Prescribing; D005568:Forms and Records Control; D006753:Hospital Records; D006769:Hospitals, General; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008510:Medication Systems, Hospital / Q000706:statistics & numerical data*; D008962:Models, Theoretical; D009737:Nursing Records; D009741:Nursing Staff, Hospital; D058996:Quality Improvement; D018570:Risk Assessment; D012985:Software Design; D013030:Spain