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Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug.
Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign).
Show detailsTable 1Risk priority number (RPN) scores for components of the paper-based system for ordering, dispensing, and administering chemotherapy that exceeded 150a
| Process | Component that warranted additional concern | RPN score |
|---|---|---|
| Ordering | Generating an “OK to give” order by a chemotherapy-certified physician, who did not obtain and review all required information. This requires a nononcologist provider to hold the order until the last piece of pertinent clinical data is available before transmitting the order to receiving departments (i.e., a conditional “OK to give” order). | 360 |
| Dispensing | Not recognizing that orders were transmitted with the incorrect patient name | 420 |
| A problem with legibility associated with either handwriting or fax transmission | 280 | |
| An incorrect volume of diluent being used for reconstitution of a medication product | 200 | |
| A medication being injected into the incorrect admixture bag, if multiple products were being prepared at the same time | 224 | |
| Administration | Infusion center nursing staff not recognizing premedications that were indicated but not ordered based upon previous adverse drug reactions | 210 |
| The second infusion center nurse failing to check multiple patient identifiers | 210 | |
| The second infusion center nurse performing the required checks without recognizing an error | 210 | |
| The second infusion center nurse administering a medication by an incorrect route of administration | 200 | |
| The second infusion center nurse failing to provide patient followup | 210 |
- a
A predetermined level deemed to warrant additional analysis.
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- Table 1, Risk priority number (RPN) scores for components of the paper-based sys...Table 1, Risk priority number (RPN) scores for components of the paper-based system for ordering, dispensing, and administering chemotherapy that exceeded 150a - Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign)
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