Failure Mode and Effects Analysis of the In-Hospital Medication Process: Identification of Systemic Risks and development of Improvement strategies

Clicks: 11
ID: 337459
2026
Free PDF
Article Quality & Performance Metrics
Overall Quality
Not rated
Combines reader engagement with the AI quality analysis. This article has not been analysed, so there is no overall score — reader engagement is measured and shown alongside.
AI Quality Assessment
Not analyzed
Readership in this journal
Emerging

Ranked #161 of 164 articles by views in International journal for quality in health care : journal of the International Society for Quality in Health Care

Most read Least read

Bar heights use a square-root scale. Only the 120 most-read articles are drawn; the journal has 164 in total.

Mint this article as an NFT
Not yet minted

Create a permanent, verifiable on-chain record of this article on the Scimatic Network. The NFT is held in your Journament account, and you can withdraw it to your own wallet at any time.

5 SUSD one-off · no wallet required
Sign in to mint
Abstract
BACKGROUND: Flaws in the in-hospital medication process compromise patient safety. A structured evaluation of the process using Failure Mode and Effects Analysis (FMEA) can identify and prioritize potential risks and help to develop targeted measures to improve medication safety. METHODS: A prospective risk analysis using FMEA was conducted between February 2025 and February 2026 in a large tertiary care hospital by an interprofessional team including physicians, nurses, pharmacists, and a chief risk manager. In six structured workshops, the medication process was analyzed including admission, prescribing, order/delivery, dispensing, and discharge. Potential failure modes, their causes, and effects were identified based on expert experience and known errors from the hospitals critical incident reporting system. Each failure mode was independently rated for severity, occurrence, and detectability on a 5-point scale. Risk Priority Numbers (RPN) were calculated to prioritize risks. Based on these results, targeted mitigation strategies were developed. RESULTS: A total of 101 potential failure modes were identified, with the highest proportion in admission (n = 37; 36.6%). RPN values were moderate (median 22; IQR 14-29; range 8-53). The highest ranked risks were missing drug interaction checks (RPN = 53) and lack of dose adjustment in renal impairment (RPN = 46). Additional high-risk areas included incomplete medication histories and communication deficits at process interfaces. Contributing factors were predominantly related to human and communication domains. Mitigation strategies included standardized medication reconciliation procedures, training programs for medical staff, pharmacist consultation service, and system level interventions such as software improvements and improved communication processes. CONCLUSION: The FMEA identified specific risks within the in-hospital medication process. Furthermore, it revealed interdependencies between process stages and system level vulnerabilities. The derived measures may contribute to improved medication safety across multiple stages of care in similar hospital settings. Future studies should evaluate their implementation and impact on medication errors.
Reference Key
openalex_W7223935730 Use this key to autocite in the manuscript while using SciMatic Manuscript Manager or Thesis Manager
Authors Christian Hermann, Ute Amann, Tobias Rüther, Stefan Kääb, Catherine Glocker, Vera Smolka, Isabel Brinkmann, Caroline Rosch, Josef Hollmann, Julian Steinbrech, Martin Göring, Angela Herold, Dorothea Strobach, Maximilian Günther
Are you one of these authors? Claim your profile
Journal International journal for quality in health care : journal of the International Society for Quality in Health Care
Year 2026
DOI
10.1093/intqhc/mzag179
URL
https://doi.org/10.1093/intqhc/mzag179
Keywords Keywords not found

Citations

No citations found. To add a citation, contact the admin at info@scimatic.org

Comments

No comments yet. Be the first to comment on this article.