SCG OSC High Risk Medications
Content
9/14/2015
Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
Failure Modes and Effects Analysis (FMEA) Tool
SCG/OSC High Risk Medications
Surgical Center Of Greensboro
Greensboro, North Carolina, United States
Other
Aim: Reduce risk of High Risk Medication Errors
Process Data
Date: 11/04/2009
Step
Description
1
List High risk meds at our facility
Failure Mode
Causes
Effects
not likely as this list is a
policy containing HRMs
HRM can have adverse
outcomes
Variable negative health
issues
Step
Description
2
Purchase High Risk Meds in single dose vial, if applicable
Failure Mode
Causes
Effects
Drug could be ordered in the
wrong strength/or not in
single dose vial.
Patient to receive the wrong
dose/strength of the drug.
Adverse negative health
outcomes.
Step
Description
3
Check strength of drugs at Delivery
Failure Mode
Causes
Human error that drug
strength, type of drug, dose
of drug was overlooked
during order process.
Packaging looks similar. Staff Wrong strength / dose is
is rushed/interrupted
placed in department for use.
performing duties.
Step
Description
4
HRM's labeled when received
Effects
Failure Mode
Causes
Effects
Pharmacy nurse neglects to
place "high alert double
check" sticker on incoming
medications.
Interruptions, rushing,
running out of Stickers.
HRM not recognized as such
if label missing. HRM not
being segregated from other
meds per policy. Without
label HRM may not be double
checked as this is a
reminder.
Step
Description
5
Delivery of HRM to Departments
Failure Mode
Causes
Effects
The wrong drug
may be distributed to the
wrong department.
Wrong drug is placed in
wrong tote for department
delivery. Rushing and
interruptions.
Employees have to find
missing drug if delivered to
wrong department.
Step
Description
6
HRM in depts. are separated & labeled.
Failure Mode
Causes
HRM sticker was removed or
unbagged and drugs were
not separated or labeled as
HRM.
Personnel in department
HRM may be placed in area
removed drug from bag with with look alike drug and used
High Alert sticker and not
inadvertently as that drug.
segregated from other drugs.
Step
Description
7
HRM administration done with double check
Failure Mode
Causes
The double check by self
Need to quickly distribute
may not be done. The double medications, and short
check with appropriate staff staffing may lead to not
Effects
Effects
Not doing the self check and
double check with
appropriate staff may lead to
Occ Det Sev RPN Actions
2
2
1
4 Keep assessing the updates
to National list of High Risk
Meds in relation to our
formulary
Occ Det Sev RPN Actions
7
7
10
490 Double check drug order
when ordered. Order as SDV
when applicable. Double
check drug strength when
received.
Double check drug when
administering.
Occ Det Sev RPN Actions
3
7
10
210 Review drug orders for
accuracy, especially
strength/ dose of high risk
meds.
Review on delivery all HRMs
for strength and dose.
Occ Det Sev RPN Actions
2
8
10
160 Double checking drugs
delivered and making sure
"high alert double check"
stickers are placed
appropriately on all HRM.
Occ Det Sev RPN Actions
5
9
10
450 Paying attention to
distribution of HRM to
appropriate departments.
Reminding staff to double
check High alert stickered
drugs.
Occ Det Sev RPN Actions
3
8
10
240 Double Checking of Storage
of all drugs so they are
properly separated and
stored.
Occ Det Sev RPN Actions
3
5
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9683&ScenarioId=11215&Type=1
10
150 Never administer HRM
without the double check
method due to increased risk
1/3
9/14/2015
Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
may not be done.
going through the
appropriate steps.
administration of a harmful
or fatal drug dosing or wrong
drug.
Step
Description
8
Multi Dose vial Insulin requires double check with another nurse
Failure Mode
Causes
The insulin dose may require
immediate administration and
therefore increase the risk of
error and omitting the double
check.
Rushing to administer dose to Effect of wrong drug /wrong
prevent deterioration of
dose may be critical in some
status of patient, may create cases.
forgetting double check.
Step
Description
9
Heparin kept in Pharmacy till ordered
Effects
Failure Mode
Causes
Effects
Heparin may inadvertantly be
placed in another
department's tote for
delivery rather than being
kept in Pharmacy.
Pharmacy nurse rushing or
another individual who is
undertaking that job and not
being careful with proper
handling of HRMs.
Heparin in larger dose than
100units/ml. being
inadvertently placed and
used in another department.
Step
Description
10
Heparin orders sent to Pharmacy
Failure Mode
Causes
Heparin orders not sent to
The preop order not sent to
pharmacy will be retrieved in pharmacy in a timely manner
panic mode and the dose or or lost.
drug may have an increased
risk of error in
administration.
Step
Description
11
Order bagged as HRM with patient order inside
Effects
The panic in following all the
appropriate steps to obtain
proper drug / dose to proper
patient wil be at risk.
Failure Mode
Causes
Effects
The patient order may
incorrectly filled. The
appropriate amount or wrong
med may be placed in bag.
The order may not be clear
as written or unclearly
written due to difficulty in
reading handwritting.
Inappropriate drug will be
placed in bag or
inappropriate dose will be
placed in bag.
Step
Description
12
Sealed bag & copy of order sent to Department
Failure Mode
Causes
Effects
The order may not be placed
in the bag and therefore may
not be the appropriate
patient's order when the bag
is sealed.
The routine is not followed
when new person is filling
preop order for that
department.
Incorrect HRM may go to
incorrect patient department
or bag.
Step
Description
13
Prior to administration of HRM double check 5Rs & expiration
Failure Mode
Causes
Effects
Prior to administration of
HRM's the nurse may forget
the double check and 5Rs &
ckg. expiration dates creating
med error.
Short staffing, rushing and
not taking the proper steps
as self check & the 5 R's and
double check methods, which
should be reveiwed in
orientation.
The negating of routine steps
which are placed to deter
med errors of HRM's are the
reasons they may occur.
Step
Description
14
Unused HRM are rebagged with order to next department
Failure Mode
Causes
HRM does not get returned to Staff is rushed, not paying
bag and placed inadvertently attention or interrupted and
in department and may be
human error results.
used as another drug.
Effects
HRM is now placed with
regular departmental drugs
and may be used as a look
alike drug by mistake.
Step
Description
15
All high dose Heparin needs to be returned to Pharmacy via bag
containing order
Failure Mode
Causes
HR Heparin may be left in
Staff rushing, interruptions
department and inadvertently and not paying attention
placed with regular drugs.
while using HRM
Effects
HRM will be left in
department and placed with
regular meds and
inadvertently be used as a
look alike drug and be used
in error.
of med error.
Occ Det Sev RPN Actions
5
5
10
250 Never Administer HRM
without Double check system
taking place with at least one
other appropriate individual.
Occ Det Sev RPN Actions
2
8
10
160 Heparin in high dose form of
greater than 100 units per
ml. must be recognized as
HRM and appropriately
bagged and labeled with
"high alert double check"
sticker.
Occ Det Sev RPN Actions
3
9
10
270 Preop orders for specific
HRM's should be copied and
sent to both preop and
pharmacy in a timely
manner for proper filling and
labeling per patient/doctor
order.
Occ Det Sev RPN Actions
2
9
10
180 The understanding and read
ability of the order is critical
to fullfilling the order for
preparation in the bag and
labeling it as HRM. Any
questions should initiate call
to physician for clarification.
Occ Det Sev RPN Actions
1
9
10
90 The following of routine
steps when dealing with
HRM's is put in place to
assist in prevention of
anticipated errors occurring
and should be followed.
Occ Det Sev RPN Actions
2
7
10
140 Imperative to Review with
new nurses on staff the HRM
Policy and our treatment of
routine steps in dealing with
HRMs to prevent errors.
Occ Det Sev RPN Actions
4
8
10
320 Paying full attention when
working with HRM use of the
double check system with
another person should
prevent occurrence.
Occ Det Sev RPN Actions
4
8
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9683&ScenarioId=11215&Type=1
10
320 Always be attentive when
using HRM and follow double
check procedure.
2/3
9/14/2015
Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
Step
Description
16
Restock HRM and shred patient order
Failure Mode
Causes
Pharmacy nurse fails to
segregate drug as HRM and it
is placed with regular
pharmaceuticals.
Staff member returning drug HRM may be considered a
may leave it or pharmacy
look alike drug and used as
nurse may be rushed and
another drug.
inadvertently place it with
regular meds.
Effects
Occ Det Sev RPN Actions
4
8
10
320 Staying focused on HRM and
not allowing interuptions or
to be rushed so drug can be
properly stored.
Calculated Totals
Total Risk Priority Number for the process
3754
Occ: Likelihood of Occurrence (110)
Det: Likelihood of Detection (110)
NOTE: 1 = Very likely it WILL be detected
10 = Very likely it WILL NOT be detected
Sev: Severity (110)
RPN: Risk Priority Number (Occ × Det × Sev)
Annotation
None
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9683&ScenarioId=11215&Type=1
3/3
Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
Failure Modes and Effects Analysis (FMEA) Tool
SCG/OSC High Risk Medications
Surgical Center Of Greensboro
Greensboro, North Carolina, United States
Other
Aim: Reduce risk of High Risk Medication Errors
Process Data
Date: 11/04/2009
Step
Description
1
List High risk meds at our facility
Failure Mode
Causes
Effects
not likely as this list is a
policy containing HRMs
HRM can have adverse
outcomes
Variable negative health
issues
Step
Description
2
Purchase High Risk Meds in single dose vial, if applicable
Failure Mode
Causes
Effects
Drug could be ordered in the
wrong strength/or not in
single dose vial.
Patient to receive the wrong
dose/strength of the drug.
Adverse negative health
outcomes.
Step
Description
3
Check strength of drugs at Delivery
Failure Mode
Causes
Human error that drug
strength, type of drug, dose
of drug was overlooked
during order process.
Packaging looks similar. Staff Wrong strength / dose is
is rushed/interrupted
placed in department for use.
performing duties.
Step
Description
4
HRM's labeled when received
Effects
Failure Mode
Causes
Effects
Pharmacy nurse neglects to
place "high alert double
check" sticker on incoming
medications.
Interruptions, rushing,
running out of Stickers.
HRM not recognized as such
if label missing. HRM not
being segregated from other
meds per policy. Without
label HRM may not be double
checked as this is a
reminder.
Step
Description
5
Delivery of HRM to Departments
Failure Mode
Causes
Effects
The wrong drug
may be distributed to the
wrong department.
Wrong drug is placed in
wrong tote for department
delivery. Rushing and
interruptions.
Employees have to find
missing drug if delivered to
wrong department.
Step
Description
6
HRM in depts. are separated & labeled.
Failure Mode
Causes
HRM sticker was removed or
unbagged and drugs were
not separated or labeled as
HRM.
Personnel in department
HRM may be placed in area
removed drug from bag with with look alike drug and used
High Alert sticker and not
inadvertently as that drug.
segregated from other drugs.
Step
Description
7
HRM administration done with double check
Failure Mode
Causes
The double check by self
Need to quickly distribute
may not be done. The double medications, and short
check with appropriate staff staffing may lead to not
Effects
Effects
Not doing the self check and
double check with
appropriate staff may lead to
Occ Det Sev RPN Actions
2
2
1
4 Keep assessing the updates
to National list of High Risk
Meds in relation to our
formulary
Occ Det Sev RPN Actions
7
7
10
490 Double check drug order
when ordered. Order as SDV
when applicable. Double
check drug strength when
received.
Double check drug when
administering.
Occ Det Sev RPN Actions
3
7
10
210 Review drug orders for
accuracy, especially
strength/ dose of high risk
meds.
Review on delivery all HRMs
for strength and dose.
Occ Det Sev RPN Actions
2
8
10
160 Double checking drugs
delivered and making sure
"high alert double check"
stickers are placed
appropriately on all HRM.
Occ Det Sev RPN Actions
5
9
10
450 Paying attention to
distribution of HRM to
appropriate departments.
Reminding staff to double
check High alert stickered
drugs.
Occ Det Sev RPN Actions
3
8
10
240 Double Checking of Storage
of all drugs so they are
properly separated and
stored.
Occ Det Sev RPN Actions
3
5
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9683&ScenarioId=11215&Type=1
10
150 Never administer HRM
without the double check
method due to increased risk
1/3
9/14/2015
Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
may not be done.
going through the
appropriate steps.
administration of a harmful
or fatal drug dosing or wrong
drug.
Step
Description
8
Multi Dose vial Insulin requires double check with another nurse
Failure Mode
Causes
The insulin dose may require
immediate administration and
therefore increase the risk of
error and omitting the double
check.
Rushing to administer dose to Effect of wrong drug /wrong
prevent deterioration of
dose may be critical in some
status of patient, may create cases.
forgetting double check.
Step
Description
9
Heparin kept in Pharmacy till ordered
Effects
Failure Mode
Causes
Effects
Heparin may inadvertantly be
placed in another
department's tote for
delivery rather than being
kept in Pharmacy.
Pharmacy nurse rushing or
another individual who is
undertaking that job and not
being careful with proper
handling of HRMs.
Heparin in larger dose than
100units/ml. being
inadvertently placed and
used in another department.
Step
Description
10
Heparin orders sent to Pharmacy
Failure Mode
Causes
Heparin orders not sent to
The preop order not sent to
pharmacy will be retrieved in pharmacy in a timely manner
panic mode and the dose or or lost.
drug may have an increased
risk of error in
administration.
Step
Description
11
Order bagged as HRM with patient order inside
Effects
The panic in following all the
appropriate steps to obtain
proper drug / dose to proper
patient wil be at risk.
Failure Mode
Causes
Effects
The patient order may
incorrectly filled. The
appropriate amount or wrong
med may be placed in bag.
The order may not be clear
as written or unclearly
written due to difficulty in
reading handwritting.
Inappropriate drug will be
placed in bag or
inappropriate dose will be
placed in bag.
Step
Description
12
Sealed bag & copy of order sent to Department
Failure Mode
Causes
Effects
The order may not be placed
in the bag and therefore may
not be the appropriate
patient's order when the bag
is sealed.
The routine is not followed
when new person is filling
preop order for that
department.
Incorrect HRM may go to
incorrect patient department
or bag.
Step
Description
13
Prior to administration of HRM double check 5Rs & expiration
Failure Mode
Causes
Effects
Prior to administration of
HRM's the nurse may forget
the double check and 5Rs &
ckg. expiration dates creating
med error.
Short staffing, rushing and
not taking the proper steps
as self check & the 5 R's and
double check methods, which
should be reveiwed in
orientation.
The negating of routine steps
which are placed to deter
med errors of HRM's are the
reasons they may occur.
Step
Description
14
Unused HRM are rebagged with order to next department
Failure Mode
Causes
HRM does not get returned to Staff is rushed, not paying
bag and placed inadvertently attention or interrupted and
in department and may be
human error results.
used as another drug.
Effects
HRM is now placed with
regular departmental drugs
and may be used as a look
alike drug by mistake.
Step
Description
15
All high dose Heparin needs to be returned to Pharmacy via bag
containing order
Failure Mode
Causes
HR Heparin may be left in
Staff rushing, interruptions
department and inadvertently and not paying attention
placed with regular drugs.
while using HRM
Effects
HRM will be left in
department and placed with
regular meds and
inadvertently be used as a
look alike drug and be used
in error.
of med error.
Occ Det Sev RPN Actions
5
5
10
250 Never Administer HRM
without Double check system
taking place with at least one
other appropriate individual.
Occ Det Sev RPN Actions
2
8
10
160 Heparin in high dose form of
greater than 100 units per
ml. must be recognized as
HRM and appropriately
bagged and labeled with
"high alert double check"
sticker.
Occ Det Sev RPN Actions
3
9
10
270 Preop orders for specific
HRM's should be copied and
sent to both preop and
pharmacy in a timely
manner for proper filling and
labeling per patient/doctor
order.
Occ Det Sev RPN Actions
2
9
10
180 The understanding and read
ability of the order is critical
to fullfilling the order for
preparation in the bag and
labeling it as HRM. Any
questions should initiate call
to physician for clarification.
Occ Det Sev RPN Actions
1
9
10
90 The following of routine
steps when dealing with
HRM's is put in place to
assist in prevention of
anticipated errors occurring
and should be followed.
Occ Det Sev RPN Actions
2
7
10
140 Imperative to Review with
new nurses on staff the HRM
Policy and our treatment of
routine steps in dealing with
HRMs to prevent errors.
Occ Det Sev RPN Actions
4
8
10
320 Paying full attention when
working with HRM use of the
double check system with
another person should
prevent occurrence.
Occ Det Sev RPN Actions
4
8
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9683&ScenarioId=11215&Type=1
10
320 Always be attentive when
using HRM and follow double
check procedure.
2/3
9/14/2015
Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
Step
Description
16
Restock HRM and shred patient order
Failure Mode
Causes
Pharmacy nurse fails to
segregate drug as HRM and it
is placed with regular
pharmaceuticals.
Staff member returning drug HRM may be considered a
may leave it or pharmacy
look alike drug and used as
nurse may be rushed and
another drug.
inadvertently place it with
regular meds.
Effects
Occ Det Sev RPN Actions
4
8
10
320 Staying focused on HRM and
not allowing interuptions or
to be rushed so drug can be
properly stored.
Calculated Totals
Total Risk Priority Number for the process
3754
Occ: Likelihood of Occurrence (110)
Det: Likelihood of Detection (110)
NOTE: 1 = Very likely it WILL be detected
10 = Very likely it WILL NOT be detected
Sev: Severity (110)
RPN: Risk Priority Number (Occ × Det × Sev)
Annotation
None
http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=9683&ScenarioId=11215&Type=1
3/3
