Abstract:
Intravenous (IV) medication is integral component of clinical care for
hospitalized patient. Errors associated with IV medication can cause detrimental patient
outcome. It affects patient life and can increase health care cost. It also involves high
risk since it is delivered directly into the patients’ blood stream. As part of quality by
design (QbD), Failure Mode Effect Analysis (FMEA) is a proactive tool used to analyze
risks, identify failures and prioritize remedial measures. The major advantage of FMEA
over other quality improvement schemes is the information gathered that makes it easy
to identify the priorities of any actions required for improvement.
Objective: - To assess prevalence, causes and severity of IV medication errors using
FMEA in Mettu Karl Hospital, South West Ethiopia.
Method: - Hospital based prospective cross sectional study was conducted for one
month from January 30 to February 28, 2014 by using direct cross sectional observation
of IV medication preparation and administration. Data was analyzed by using SPSS
version 16.0 statistical software package. Frequencies of descriptive statistics were
presented by using percentages and table. Binary, back ward logistic regression analysis
was performed to assess factors associated with IV medication failure mode to identify
only significant root causes. We use R-soft ware for rating and categorizing of high
Risk Priority Numbers along severity versus occurrence and detectability as failure
mode effect analysis standard. Statistical significance was defined at a level of 0.05.
Result: From 123 IV medication preparation, 12 failure modes and 33 associated
factors were identified. Aseptic technique was the most observed error, 106(86.2%);
Followed by 94(76.4%) of wrong time and 92(74.8%) of wrong rate. Human factor,
71(57.7%) was the most contributing factor observed. Surgical ward (75.0%) and
Gynecology ward (62.0%), were the first, and second wards in which IV medication
failure mode was observed.
Conclusion: This study shows that there was a serious IV medication failure mode in
each wards and needs prompt intervention.
