CLINICAL RISK ASSESING AND MANAGEMENT IN MEDICATION PROCESS OF CCU BY HFMEA

Nowadays, medication errors as the most common medical error are among the most important health and safety issues for patient safety. The aim of this study was Assessing and Management of Clinical Risk in medication Process of CCU in Mashhad teaching hospitals by HFMEA Method.

The present study is a combination (qualitative – quantitative, cross sectional -descriptive) method. Data was collected through direct observation, review of documents, FGD technique by Non-probabilistic sampling based on purpose and by HFMEA standard work-sheet to risk analysis, decision tree analysis, identifying the root causes of failure states and suggestion of Improvement measures. In this study Fuzzy AHP (Analytical hierarchy process) Technique for selecting Priority Process, the Eindhoven model (ECM) was used and the Idea Generation Method was used to suggestion Improvement measures. Finally, data was analyzed using Excel software by descriptive statistics.

A total of 50 failure states in the 5-step medication process were identified, so that failure states were identified as unacceptable risk.so that from the total root causes of erorrs were categorized based on the ECM model, 62.7% of latent errors and 37.3% of obvious errors and Improving measures were suggested., if these strategies are implemented, in the re-evaluated Controlled Risk The ratio of unacceptable risks will decrease from 56.9% to 21.6%.

The essential medication process due to Medicinal errors in some cases instead of treatment may increased costs, injury and prolonged hospital stay. The HFMEA Method with preventive approach and the focusing of systems rather than individual errors, in order to identify and resolve increases the agreement on process and organizational weakness and can play an Effectiveness role in eliminate the root causes of errors, especially in the sensitive and complex of the CCU ward.