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 inMashhad teaching hospitals by HFMEA
Method.
Materials & Methods: 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.
Results: 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%.
Conclusion: The essential medication process due toMedicinal errors in some cases instead of treatment
may increased costs, injury and prolonged hospital stay. The HFMEAMethod 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.