Aim. The aim of the present work is to provide improved safety and quality in care procedures, through the analysis of existing processes within the Nuclear Medicine Unit, in order to identify activities at higher risk and set in before they cause harm to the patient. Materials and methods. The first step was the settlement of the team appointed for the analysis: a multi-professional group consisting of 7 operators of Nuclear Medicine Unit and 3 operators trained in the use of FMEA / FMECA (Failure Mode and Effect Analysis / Failure Mode and Critical Effect Analysis) technology. The analysis was conducted using the FMEA/FMECA method applied as follow: mapping of processes in the Nuclear Medicine Unit; systematic description and analysis of each activity; identification of possible sources of error and failure modes for each task mapped; definition of priority index of risk (PIR score i.e. result of the product between the severity, probability and detection); analysis of barriers; analysis of causes that break barriers; identification and definition of potential actions and corrective measures able to reduce the risk of error. Each member of the working group evaluated the questions “what can happen?” “what are we doing to prevent the error?” for each activity, then, risk of error probability, detection and gravity were scored using standardized scales. The PIR score for each identified failure mode was subsequently calculated. The average score assigned to each critical process were calculated for both the near misses and occurred accidents, thus being able to identify priority intervention processes. Eventually the assessment of the effectiveness of the implemented preventive actions was carried out. Results. The process "Clinical Management of Radiopharmaceuticals" has proven to be the "primary process" at major risk and the application of FMEA/FMECA method on it resulted in 43% risk reduction in the activities with high score and in the whole process during a period of about six month. Conclusions. The implementation of the method FMEA/FMECA in "Clinical Management of Radiopharmaceuticals" have reduced significantly the risk of adverse events.
Proactive Implementation of Quantitative Analysis of the Risk FMEA / FMECA in Nuclear Medicine Procedures
UCCELLI, Licia;
2012
Abstract
Aim. The aim of the present work is to provide improved safety and quality in care procedures, through the analysis of existing processes within the Nuclear Medicine Unit, in order to identify activities at higher risk and set in before they cause harm to the patient. Materials and methods. The first step was the settlement of the team appointed for the analysis: a multi-professional group consisting of 7 operators of Nuclear Medicine Unit and 3 operators trained in the use of FMEA / FMECA (Failure Mode and Effect Analysis / Failure Mode and Critical Effect Analysis) technology. The analysis was conducted using the FMEA/FMECA method applied as follow: mapping of processes in the Nuclear Medicine Unit; systematic description and analysis of each activity; identification of possible sources of error and failure modes for each task mapped; definition of priority index of risk (PIR score i.e. result of the product between the severity, probability and detection); analysis of barriers; analysis of causes that break barriers; identification and definition of potential actions and corrective measures able to reduce the risk of error. Each member of the working group evaluated the questions “what can happen?” “what are we doing to prevent the error?” for each activity, then, risk of error probability, detection and gravity were scored using standardized scales. The PIR score for each identified failure mode was subsequently calculated. The average score assigned to each critical process were calculated for both the near misses and occurred accidents, thus being able to identify priority intervention processes. Eventually the assessment of the effectiveness of the implemented preventive actions was carried out. Results. The process "Clinical Management of Radiopharmaceuticals" has proven to be the "primary process" at major risk and the application of FMEA/FMECA method on it resulted in 43% risk reduction in the activities with high score and in the whole process during a period of about six month. Conclusions. The implementation of the method FMEA/FMECA in "Clinical Management of Radiopharmaceuticals" have reduced significantly the risk of adverse events.I documenti in SFERA sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
