M Berruyer1, S Atkinson1, D Lebel1, J-F Bussières2. 1. Unité de recherche en pratique pharmaceutique, département de pharmacie, CHU Sainte-Justine, 3175 Côte-Sainte-Catherine, H3T 1C5 Montréal, Canada. 2. Unité de recherche en pratique pharmaceutique, département de pharmacie, CHU Sainte-Justine, 3175 Côte-Sainte-Catherine, H3T 1C5 Montréal, Canada; Faculté de pharmacie, université de Montréal, Montréal, Canada. Electronic address: jf.bussieres@ssss.gouv.qc.ca.
Abstract
CONTEXT AND OBJECTIVES: Insulin is a high-alert drug. The main objective of this descriptive cross-sectional study was to evaluate the risks associated with insulin use in healthcare centers. The secondary objective was to propose corrective measures to reduce the main risks associated with the most critical failure modes in the analysis. METHODS: We conducted a failure mode and effects analysis (FMEA) in obstetrics-gynecology, neonatology and pediatrics. RESULTS: Five multidisciplinary meetings occurred in August 2013. A total of 44 out of 49 failure modes were analyzed. Nine out of 44 (20%) failure modes were deemed critical, with a criticality score ranging from 540 to 720. DISCUSSION: Following the multidisciplinary meetings, everybody agreed that an FMEA was a useful tool to identify failure modes and their relative importance. This approach identified many corrective measures. CONCLUSION: This shared experience increased awareness of safety issues with insulin in our mother-child center. This study identified the main failure modes and associated corrective measures.
CONTEXT AND OBJECTIVES:Insulin is a high-alert drug. The main objective of this descriptive cross-sectional study was to evaluate the risks associated with insulin use in healthcare centers. The secondary objective was to propose corrective measures to reduce the main risks associated with the most critical failure modes in the analysis. METHODS: We conducted a failure mode and effects analysis (FMEA) in obstetrics-gynecology, neonatology and pediatrics. RESULTS: Five multidisciplinary meetings occurred in August 2013. A total of 44 out of 49 failure modes were analyzed. Nine out of 44 (20%) failure modes were deemed critical, with a criticality score ranging from 540 to 720. DISCUSSION: Following the multidisciplinary meetings, everybody agreed that an FMEA was a useful tool to identify failure modes and their relative importance. This approach identified many corrective measures. CONCLUSION: This shared experience increased awareness of safety issues with insulin in our mother-child center. This study identified the main failure modes and associated corrective measures.