title: Risk Assessment of Drug Management Process in Women Surgery Department of Qaem Educational Hospital (QEH) Using HFMEA Method (2013).
abstract: Evaluation and improvement of drug management process are essential for patient safety. The present study was performed whit the aim of assessing risk of drug management process in Women Surgery Department of QEH using HFMEA method in 2013. A mixed method was used to analyze failure modes and their effects with HFMEA. To classify failure modes; nursing errors in clinical management model, for classifying factors affecting error; approved model by the UK National Health System, and for determining solutions for improvement; Theory of Inventive Problem Solving, were used. 48 failure modes were identified for 14 sub-process of five steps drug management process. The frequency of failure modes were as follow :35.3% in supplying step, 20.75% in prescription step, 10.4% in preparing step, 22.9% in distribution step and 10.35% in follow up and monitoring step. Seventeen failure modes (35.14%) were considered as non-acceptable risk (hazard score≥ 8) and were transferred to decision tree. Among 51 Influencing factors, the most common reasons for error were related to environmental factors (21.5%), and the less common reasons for error were related to patient factors (4.3%). HFMEA is a useful tool to evaluating, prioritization and analyzing failure modes in drug management process. Revision drug management process based focus-PDCA, assessing adverse drug reactions (ADR), USE patient identification bracelet, holding periodical pharmaceutical conferences to improve personnel knowledge, patient contribution in drug therapy; are performance solutions which were placed in work order.
authors.affiliation: Department of Ergonomics, Faculty of Health, Safety and Environment, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Reza
authors.initials: R
authors.lastname: Khani-Jazani
authors.affiliation: Student Research Committee, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Yasamin
authors.initials: Y
authors.lastname: Molavi-Taleghani
authors.affiliation: Health Management and Economics Research Center, Iran University of Medical Sciences,, Tehran, Iran.
authors.forename: Hesam
authors.initials: H
authors.lastname: Seyedin
authors.affiliation: Health Sciences Research Center, Department of Health and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Ali
authors.initials: A
authors.lastname: Vafaee-Najar
authors.affiliation: Research Center for Health Services Management, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
authors.forename: Hossein
authors.initials: H
authors.lastname: Ebrahimipour
authors.affiliation: Student Research Committee, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Arefeh
authors.initials: A
authors.lastname: Pourtaleb
keywords: Effects analysis; Healthcare failure mode; Medication therapy management; Risk assessment