Intravenöz Ilaç Uygulama Hatalarının Hata Türleri ve Etkilerinin Analizine Göre Incelenmesi: Bir Iyileştirme Çalışması

Abstract

This analytic, semi-experimental study was conducted to identify medication errors according to failure mode and effect analysis and effects of improvement program on medication errors. The universe of study is comprised from nurses working Denizli Servergazi State Hospital intensive care units of anesthesiology and reanimation, general surgery, coronary (N=49) and intravenous medication administrations held for a year in these units. In order to determine the current situation, failure mode and effect analysis was conducted and then 463 intravenous medication administration was observed. Nurses were given education related with intravenous medication administartion and medication errors and then pre-and post multiple choice test questions was applied to determine their level of knowledge. The result of these practices are evaluated and created an improvement work that consist of intravenous medication administration standard, a printed and virtual file related with intravenous medication adminstration and medication errors, the consultant pharmacist, and these practices remained for three months. At the end of this period in order to evaluate the effectiveness of the improvement work, failure mode and effect analysis was reconducted and nurses' intravenous medication administrations (n=132) was observed. Numbers, percentages, mean, standard deviation, multiple choice test scores, priority risk numbers for failure mode and effects analysis were used in data assessment. According to findings, there were no errors at prescribing and verification of patient at before and after improvement s. At preparation of medication step, the error rate reduced from 34.10% to 25%. At administration of medication, recording, patient monitoring and medication teaching step, the error rate was constant as 100% before and after improvement work. The error types and areas determined by failure mode and effect analysis scores were decreased. Research recommendations are made based on the results.