Application of FMEA model and 6S management method in reducing dispensing errors in PIVAS of children’s hospitals

HE Linfeng; YANG Yaya; LIN Yunzhu; YANG Chunsong; ZHANG Lingli

doi:10.6039/j.issn.1001-0408.2024.02.20

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Application of FMEA model and 6S management method in reducing dispensing errors in PIVAS of children’s hospitals

更新时间：2024-01-24

- Application of FMEA model and 6S management method in reducing dispensing errors in PIVAS of children’s hospitals
- ZHONGGUO YAOFANG Vol. 35, Issue 2, Pages: 237-241(2024)
- 作者机构：
  
  1.四川大学华西第二医院药学部/循证药学中心，成都　610041
  2.四川大学出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041
- 作者简介：
- 基金信息：
- DOI：10.6039/j.issn.1001-0408.2024.02.20
  CLC： R952
- Published：30 January 2024，
  
  Received：17 May 2023，
  
  Revised：27 December 2023，
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何林峰,杨亚亚,林芸竹等.FMEA模型和6S管理方法在降低儿童专科医院PIVAS调剂差错中的应用 ^Δ[J].中国药房,2024,35(02):237-241.

HE Linfeng,YANG Yaya,LIN Yunzhu,et al.Application of FMEA model and 6S management method in reducing dispensing errors in PIVAS of children’s hospitals[J].ZHONGGUO YAOFANG,2024,35(02):237-241.
何林峰,杨亚亚,林芸竹等.FMEA模型和6S管理方法在降低儿童专科医院PIVAS调剂差错中的应用 ^Δ[J].中国药房,2024,35(02):237-241. DOI： 10.6039/j.issn.1001-0408.2024.02.20.

HE Linfeng,YANG Yaya,LIN Yunzhu,et al.Application of FMEA model and 6S management method in reducing dispensing errors in PIVAS of children’s hospitals[J].ZHONGGUO YAOFANG,2024,35(02):237-241. DOI： 10.6039/j.issn.1001-0408.2024.02.20.

摘要

目的

降低儿童专科医院静脉药物配置中心（PIVAS）的调剂差错。

方法

采用失效模式和效应分析（FMEA）模型，对我院PIVAS调剂流程进行风险识别，找出各环节中可能导致调剂差错的潜在失效模式，分析其失效原因，并对潜在失效模式的严重度、发生率和检测度进行量化评分，计算其风险优先指数，从而筛选需要优先改善的失效模式；应用6S管理方法，从整理（seiri）、整顿（seiton）、清扫（seiso）、清洁（seiketsu）、素养（shitsuke）和安全（safety）6个方面制定相应的改善措施，并对实施前后的干预效果进行评价。

结果

根据风险优先指数评估筛选出32个潜在失效模式，其中需要优先改善的关键失效模式共18个。根据6S管理方法采取相应措施后，18个关键失效模式的风险优先指数均有所下降，风险优先指数值由497降至142，降幅达71.43%；其中15个关键失效模式的差错率均较实施前显著降低（

＜0.05）。

结论

应用FMEA模式和6S管理方法对PIVAS工作流程的各环节进行风险管控的预测和改进，能有效降低PIVAS调剂差错风险，保障儿童静脉用药安全。

Abstract

OBJECTIVE

To reduce dispensing errors in pharmacy intravenous admixture service （PIVAS） of children’s hospitals.

METHODS

The risk of dispensing procedures in our PIVAS was identified by applying failure mode and effect analysis （FMEA） model. Potential failure modes that might lead to dispensing errors in each link were determined， and failure causes were analyzed. The severity， incidence and detection degree of potential failure modes were quantitatively scored， and their risk priority number （RPN） was calculated to screen failure modes that needed to be improved in priority； the corresponding improvement measures were developed by 6S management method from six aspects， namely， finishing （seiri）， rectifying （seiton）， sweeping （seiso）， sanitation （seiketsu）， literacy （shitsuke） and safety. The effect of intervention before and after rectification was evaluated.

RESULTS

Based on the RPN， 32 potential failure modes were selected， of which a total of 18 critical failure modes that needed to be improved in priority. After implementing corresponding measures according to 6S management method， the RPN of 18 critical failure modes decreased. The total RPN decreased from 497 to 142 with a decrease rate of 71.43%. The error rates of 15 critical failure modes were significantly lower than before implementation （

＜0.05）.

CONCLUSIONS

Applying FMEA model and 6S management method to the risk control of all aspects of PIVAS workflow can effectively reduce the risk of PIVAS dispensing errors and ensure the safety of children’s intravenous medication.

关键词

静脉药物配置中心调剂差错风险评估失效模式和效应分析6S管理

Keywords

dispensing errorsrisk evaluationfailure mode and effect analysis6S management

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