The process for the administration of a medicine was associated with 21 failure modes. The average priority risk numbers for the five teams ranged from 10 to 100. The three risks associated with a high score of 100 were failure of the double check of both the medicine and of the dose, and use of unlabelled syringes. Scores of 80 were associated with the patient not knowing their medicines; medicines being drawn
up/selected by one practitioner and administered by another buy Epacadostat and the reliability of the record of the time of medicine administration. A standard medicines process was rolled out across the Trust: Prefilled Syringes are used to reduce the risk of medicine and dose errors. When not available standardised syringe labels are applied whenever a syringe is handed from one person to another and when doses are titrated; Medicines are left in the manufacturers’ containers and are packed into a range of five coloured bags. This make products physically distinct and medicine information is also available for the clinician and the patient;
Only one strength of each medicines is supplied (where practical) to reduce the chance of dose errors. FMEA was an effective tool to review the INNO-406 purchase processes that can lead to medicines errors. It generated considerable discussion, allowed a consensus to be reached and has given teams some ownership of the medicines administration process. The tool is also useful in making new paramedics aware of medicines risks; the paramedics discuss how the above data compares with their perceptions. We do not know whether FMEA has reduced medicines errors. Reporting of errors has increased but this may be a result of an increased awareness of the issues. A review of medicines errors and processes is now ongoing. 1. Failure Modes and Effects Analysis (FMEA) Tool. 2013. Failure Modes and Effects Analysis (FMEA) Tool. [ONLINE] Available at: Pregnenolone http://www.ihi.org/knowledge/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx.
[Accessed 24 April 2013]. Ian Cubbin1, Andy McAlavey2, Nathan O’Brien1 1Liverpool John Moores University, Liverpool, Merseyside, UK, 2Great Sutton Medical Centre, Ellesmere Port, Flintshire, UK Specials are used for treatment of patients when no licenced alternative medicine is available. Of the 92267 patients are registered in the area, 185 received specials at a cost of £157,700. Investigation of costs identified differences of up to £580 for near equivalent items. A ‘Special’ is an unlicensed medicine manufactured to fulfil a ‘special need’, in response to an unsolicited order from a qualified health care professional. It presupposes that no licensed medical alternative is available. It is exempt from the need for a marketing authorisation licence.1 The aim of this work was to determine where and why specials are used and the impact on patient care and NHS drug costs.
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