Aplicación del Análisis Modal de Fallos y Efectos en la gestión de los riesgos de la terapia farmacológica en una unidad de cuidados intensivos

Autores/as

  • Kamila Maria Maranhão Sidney Federal University of Ceará, Faculty of pharmacy, dentistry and nursing Pharmacy Department, Fortaleza, Brazil. https://orcid.org/0000-0001-7505-620X
  • Elana Figueiredo Chaves Hospital Universitário Walter Cantídio https://orcid.org/0000-0002-5817-0999
  • Jeanine Morais Pereira Maternity School Assis Chateaubriand, Multiprofessional Integrated Residency Program in Hospital Health Care, Fortaleza, Brazil. https://orcid.org/0000-0003-1340-8753
  • Henrique Jorge Maia Costa Messejana Hospital Dr. Carlos Alberto Studart Gomes, Fortaleza, Brazil.
  • Marta Maria de França Fonteles Federal University of Ceará, Faculty of pharmacy, dentistry and nursing Pharmacy Department, Fortaleza, Brazil.

DOI:

https://doi.org/10.30827/ars.v65i3.29973

Palabras clave:

Análisis de Riesgo, Seguridad del paciente, Calidad de los Servicios de Salud, Cuidados críticos

Resumen

Objetivo: Utilizar el Análisis de Modos de Falla y Efectos (FMEA) para gestionar los riesgos en la terapia farmacológica prescrita dentro de una Unidad de Cuidados Intensivos (UCI).

Metodología: Esta investigación-acción, que integra métodos cualitativos y cuantitativos, evalúa las prescripciones médicas en una UCI Coronaria (CECOR) en Fortaleza, Brasil, utilizando FMEA. El estudio implica definir el proceso, formar un equipo multidisciplinario, realizar un diagnóstico situacional, evaluar los modos de falla (MF) con índices de Severidad (S) y Detección (D), monitorear la Prevalencia de los MF (P) y calcular el Coeficiente de Priorización (PC). Cada MF está acompañado de recomendaciones farmacéuticas. Se diseñan actividades de educación basadas en el PC para los profesionales de CECOR.

Resultados: En el diagnóstico situacional se evaluaron 170 prescripciones y 60 MF, con las categorías principales siendo las interacciones medicamentosas (39,7 %) e incompatibilidades (30,0 %). Las causas asociadas con estos errores fueron multifactoriales. Respecto a la respuesta del equipo ante un FM, se determinó que el 36,7% de los FM serían aceptados con seguimiento. Durante el monitoreo de prevalencia, el 63,3 % de los tipos de MF ocurrieron 837 veces, con alta severidad (50,0 %) y baja detección (55,3 %). Los MF más frecuentes fueron la ausencia de forma farmacéutica (29,4 %) y dosis (8,8 %). 

Conclusión: El FMEA facilita identificar, clasificar y priorizar los riesgos en la terapia farmacológica en CECOR, subrayando su efectividad como herramienta de calidad para mejorar la seguridad del paciente.

Descargas

Los datos de descargas todavía no están disponibles.

Citas

Marshall JC, Bosco L, Adhikari NK, et al. What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care. 2017;37:270-6. doi: 10.1016/j.jcrc.2016.07.015. DOI: https://doi.org/10.1016/j.jcrc.2016.07.015

Camiré E, Moyen E, Stelfox HT. Medication errors in critical care: risk factors, prevention and disclosure. CMAJ. 2009;180(9):936-43. doi: 10.1503/cmaj.080869. DOI: https://doi.org/10.1503/cmaj.080869

Kane-Gill SL, Jacobi J, Rothschild JM. Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med. 2010;38(6 Suppl):S83-9. doi: 10.1097/CCM.0b013e3181dd8364. DOI: https://doi.org/10.1097/CCM.0b013e3181dd8364

Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.

Agency For Healthcare Research And Quality(AHRQ). Saving lives and saving money: hospital-acquired conditions update. Interim Data From National Efforts To Make Care Safer, 2010-2014. Content last updated December 2015. Agency for Healthcare Research and Quality, Rockville, MD. Available in: <https://www.ahrq.gov/hai/pfp/interimhacrate2014.html> Access: 1/5/2016.

Aspden P, Wolcott J, Bootman JL, et al, eds; Institute of Medicine, Committee on Identifying and Preventing Medication Errors. Washington DC: National Academies Press; 2007. ISBN 0309101476.

Machado APC, Tomich CSF, Osme SF, et al. Prescribing errors in a Brazilian neonatal intensive care unit. Cad. Saúde Pública. 2015;31(12):2610-20. DOI: https://doi.org/10.1590/0102-311X00194714

World Health Organization. Conceptual framework for the international classification for patient safety. Version 1.1. Final Technical Report. c2011 [cited 2018 jan 26]. Available in: https://proqualis.net/sites/proqualis.net/files/Estrutura%20Conceitual%20da%20Classifica%C3%A7%C3%A3o%20Int%20Seguran%C3%A7a%20do%20Paciente.pdf

Manual de políticas e estratégias para a qualidade dos cuidados de saúde: uma abordagem prática para formular políticas e estratégias destinadas a melhorar a qualidade dos cuidados de saúde [Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care]. Genebra: Organização Mundial da Saúde; 2020.

Galdino SV, Reis EMB, Santos CB, et al. Ferramentas de qualidade na gestão dos serviços de saúde: revisão integrativa de literatura. Revista Eletrônica Gestão & Saúde. 2016;7(1):1023–57. DOI: https://doi.org/10.18673/gs.v0isupl..22005

Liu HC, Zhang LJ, Ping YJ, et al. Failure mode and effects analysis for proactive healthcare risk evaluation: A systematic literature review. J Eval Clin Pract. 2020 Aug;26(4):1320-1337. doi: 10.1111/jep.13317. DOI: https://doi.org/10.1111/jep.13317

Vida MAC, Plata JEM, Morales-Molina JÁ, et al. Identification and prioritisation of risks in a hospital pharmacy using healthcare failure mode and effect analysis. Eur J Hosp Pharm. 2019;26(2):66-72. doi: 10.1136/ejhpharm-2017-001242. DOI: https://doi.org/10.1136/ejhpharm-2017-001242

Duwe B, Fuchs BD, Hansen-Flaschen J. Failure mode and effects analysis application to critical care medicine. Crit Care Clin. 2005;21(1):21-30, vii. doi: 10.1016/j.ccc.2004.07.005. DOI: https://doi.org/10.1016/j.ccc.2004.07.005

Sidney KM, Chaves EF, Costa HM, et al. Use of the failure mode and effect analysis tool in the clinical medication process in an intensive care unit. Rev Bras Farm Hosp Serv Saude. 2021;12(3):0606. doi: 10.30968/rbfhss.2021.123.0606. DOI: https://doi.org/10.30968/rbfhss.2021.123.0606

Hussain E, Kao E. Medication safety and transfusion errors in the ICU and beyond. Crit Care Clin. 2005 Jan;21(1):91-110, ix. doi: 10.1016/j.ccc.2004.08.003. DOI: https://doi.org/10.1016/j.ccc.2004.08.003

Ashley L, Armitage G, Neary M, et al. A practical guide to failure mode and effects analysis in health care: making the most of the team and its meetings. Jt Comm J Qual Patient Saf. 2010;36(8):351-8. doi: 10.1016/s1553-7250(10)36053-3. DOI: https://doi.org/10.1016/S1553-7250(10)36053-3

Micromedex® Healthcare Series. 2015. Avaliable in: <http://www-DRUGDEXsolutionscom.ez11.periodicos.capes.gov.br/DRUGDEX2/librarian/.> Access: 15 November 2017.

UpToDate®. 2019. Available in:<https://www.uptodate.com/contents/search> Access: 14 Jun 2019.

Seeber I, Vreede GJ, Maier R, et al. Beyond Brainstorming: Exploring Convergence in Teams. J Manag Inf Syst. 2017;34(4):939–69. doi: 10.1080/07421222.2017.1393303. DOI: https://doi.org/10.1080/07421222.2017.1393303

Picarillo AP. Introduction to quality improvement tools for the clinician. J Perinatol. 2018 Jul;38(7):929-935. doi: 10.1038/s41372-018-0100-4. Epub 2018 May 24. PMID: 29795322. DOI: https://doi.org/10.1038/s41372-018-0100-4

Farré R, Clopés A, Sala ML, et al. Intervenciones farmacéuticas (parte I): metodología y evaluación. Farm Hosp 2000; 24(3):136-44.

Instituto para Práticas Seguras no Uso de Medicamentos. Medicamentos Potencialmente Perigosos de Uso Hospitalar e Ambulatorial - Listas Atualizadas 2015. Boletim ISMP Brasil. 2015; 4(3). Available in: <http://www.ismp-brasil.org/site/wp-content/uploads/2015/12/V4N3.pdf>. Access: 12 Jun 2022.

Bosma BE, Hunfeld NGM, Roobol-Meuwese E, et al. Voluntarily reported prescribing, monitoring, and medication transfer errors in intensive care units in The Netherlands. Int J Clin Pharm. 2021;43(1):66-76. doi: 10.1007/s11096-020-01101-5. DOI: https://doi.org/10.1007/s11096-020-01101-5

Cho I, Park H, Choi YJ, et al. Understanding the Nature of Medication Errors in an ICU with a Computerized Physician Order Entry System. PLoS ONE. 2014;9(12):e114243. doi:10.1371/journal.pone.0114243

Gracia JE, Sanz AA, Serrano RB, et al. Medication errors and risk areas in a critical care unit. J Adv Nurs. 2021;77(1):286-95. doi: 10.1111/jan.14612. DOI: https://doi.org/10.1111/jan.14612

Kunac DL, Reith DM. Identification of priorities for medication safety in neonatal intensive care. Drug Saf. 2005;28(3):251-61. doi: 10.2165/00002018-200528030-00006. DOI: https://doi.org/10.2165/00002018-200528030-00006

Anjalee JAL, Rutter V, Samaranayake NR. Application of failure mode and effects analysis (FMEA) to improve medication safety in the dispensing process - a study at a teaching hospital, Sri Lanka. BMC Public Health. 2021 Jul 20;21(1):1430. doi: 10.1186/s12889-021-11369-5. DOI: https://doi.org/10.1186/s12889-021-11369-5

Malfará M, Pernassi M, Aragon D, Carlotti A. Impact of the clinical pharmacist interventions on the prevention of pharmacotherapy related problems in the pediatric intensive care unit. Int J Clin Pharm. 2018 Jun;40(3):513-9. doi: 10.1007/s11096-018-0632-x.

Rodriguez-Gonzalez CG, Martin-Barbero ML, Herranz-Alonso A, et al. Use of failure mode, effect, and criticality analysis to improve safety in the medication administration process. J Eval Clin Pract. 2015;21(4):549-59. doi: 10.1111/jep.12314. DOI: https://doi.org/10.1111/jep.12314

Stollings JL, Bloom SL, Wang L, et al. Critical Care Pharmacists and Medication Management in an ICU Recovery Center. Ann Pharmacother. 2018 Aug;52(8):713-723. doi: 10.1177/1060028018759343. DOI: https://doi.org/10.1177/1060028018759343

Adriano LS. Farmácia clínica em unidade de terapia intensiva: identificação, resolução e prevenção de erros de medicação. 2016. 76 f. Dissertação (Mestrado em Ciências Farmacêuticas) - Faculdade de Farmácia, Odontologia e Enfermagem, Universidade Federal do Ceará, Fortaleza, 2016.

Ferrández O, Casañ B, Graua S, et al. Análisis de los problemas relacionados con los medicamentos en un hospital de tercer nivel de Barcelona. Gaceta Sanitaria. 2018;33(4):361-8. doi: 10.1016/j.gaceta.2018.01.002. DOI: https://doi.org/10.1016/j.gaceta.2018.01.002

Askari M, Eslami S, Louws M, et al. Frequency and nature of drug-drug interactions in the intensive care unit. Pharmacoepidemiol Drug Saf. 2013;22(4):430-7. doi: 10.1002/pds.3415. DOI: https://doi.org/10.1002/pds.3415

Valentin A. Approaches to decreasing medication and other care errors in the ICU. Curr Opin Crit Care. 2013;19(5):474-9. doi: 10.1097/MCC.0b013e328364d4f9. DOI: https://doi.org/10.1097/MCC.0b013e328364d4f9

Lao GC, Reyes MR, Turet JR, et al. Compatibilidad de los fármacos administrados en «Y» en las unidades de cuidados intensivos: revisión sistemática. Medicina Intensiva. 2020;44(2):80-7. doi: 10.1016/j.medin.2018.08.004. DOI: https://doi.org/10.1016/j.medin.2018.08.004

Miarons M, Marín S, Amenós I, et al. Pharmaceutical interventions in the emergency department: cost-effectiveness and cost-benefit analysis. Eur J Hosp Pharm. 2021;28(3):133-8. doi: 10.1136/ejhpharm-2019-002067. DOI: https://doi.org/10.1136/ejhpharm-2019-002067

Calligaris L, Panzera A, Arnoldo L, et al. Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital. BMC Clin Pharmacol. 2009;9:9. doi: 10.1186/1472-6904-9-9. DOI: https://doi.org/10.1186/1472-6904-9-9

Cho I, Park H, Choi YJ, et al. Understanding the nature of medication errors in an ICU with a computerized physician order entry system. PLoS One. 2014;9(12):e114243. doi: 10.1371/journal.pone.0114243. DOI: https://doi.org/10.1371/journal.pone.0114243

Silveira ED, Díaz AA, Menéndez-Conde CP. Análisis modal de fallos y efectos del proceso de prescripción, validación y dispensación de medicamentos. Farm Hosp. 2012;36(1):24-32. doi: 10.1016/j.farma.2010.12.002. DOI: https://doi.org/10.1016/j.farma.2010.12.002

Duin TS, Carvalho MAF, Pype PF, et al. Junior doctors’ experiences with interprofessional collaboration: Wandering the landscape. Med Educ. 2022 Apr;56(4):418-31. doi: 10.1111/medu.14711. DOI: https://doi.org/10.1111/medu.14711

Lago P, Bizzarri G, Scalzotto F, et al. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report. BMJ Open. 2012;2(6):e001249. doi: 10.1136/bmjopen-2012-001249. DOI: https://doi.org/10.1136/bmjopen-2012-001249

Fideles GM, Alcântara-Neto JM, Peixoto-Júnior AA, et al. Pharmacist recommendations in an intensive care unit: three-year clinical activities. Rev Bras Ter Intensiva. 2015;27(2):149-54. doi: 10.5935/0103-507X.20150026. DOI: https://doi.org/10.5935/0103-507X.20150026

Silva ACS, Sousa DSC, Perraud EBC et al. Acompanhamento farmacoterapêutico em unidade de terapia intensiva respiratória: descrição e análise de resultados. Einstein. 2018;16(2): eAO4112.

Malfará M, Pernassi M, Aragon D, et al. Impact of the clinical pharmacist interventions on prevention of pharmacotherapy related problems in the paediatric intensive care unit. Int J Clin Pharm. 2018 Jun;40(3):513-519. doi: 10.1007/s11096-018-0632-x. DOI: https://doi.org/10.1007/s11096-018-0632-x

Shaughnessy AF, D’Amico F. Long-term experience with a program to improve prescription-writing skills. Fam Med. 1994;26:168–71.

Descargas

Publicado

2024-06-20

Cómo citar

1.
Maranhão Sidney KM, Figueiredo Chaves E, Morais Pereira J, Jorge Maia Costa H, de França Fonteles MM. Aplicación del Análisis Modal de Fallos y Efectos en la gestión de los riesgos de la terapia farmacológica en una unidad de cuidados intensivos. Ars Pharm [Internet]. 20 de junio de 2024 [citado 7 de noviembre de 2024];65(3):185-201. Disponible en: https://revistaseug.ugr.es/index.php/ars/article/view/29973

Número

Sección

Artículos Originales