Prospective risk management applied to medication errors in a Brazilian hospital .
Patient safety ; quality health care; Medication errors ; risk management.
Introduction: health services have increased use of complex technologies and processes that provide
high risks for patient care. Prospective methods of identification and risk reduction can be helpful, but there is little description of your application in the context brasileiro. Goal: This study aims to
describe the application of HFMEA tool in drug dispensing process, in order to prospectively know the
possible failures and its effects. Method: This is a descriptive study, developed in a university hospital, applying the steps recommended by the Veteran Administration: 1-Definition theme / process to be analyzed; 2- Constitution of the team; 3 Description graphical analysis process; 4 Identification and analysis of the risks or hazards; 5. Planning the intervention and indicators; and 6 Identification responsible for implementation and collaboration set of managers. Preliminary results: met 21 failure modes in dispensing drugs. The sub-processes with the most failure mode were, in descending order, separation of medicine (6/21 failures), prepare the dose (6/21 failures), evaluation of the prescription (3/21 failures), unitarization of drugs and delivery dose (2/21 failures), the drug release (1/21 failures) and dose conference (1/21 failures).