5PSQ-132 Failure mode and effect analysis applied to the parenteral nutrition preparation process in a maternity and neonatal hospital

Background and importanceParenteral nutrition (PN) is an intravenous nutrition technique commonly used in intensive healthcare units. Considering the lack of marketed mixtures for the neonatal population, the preparation of PN is an essential, but complex and high risk hospital activity.Aim and objectivesTo analyse the risks related to the process of preparing parenteral nutrition bags in the pharmacy department of a university maternity and neonatology hospital.Material and methodsThis FMEA was performed in the sterile preparation unit from January to April 2020. A multidisciplinary team was recruited to firstly perform a process mapping followed by related failure mode mapping through brainstorming sessions. Then, the criticality score for each failure mode was determined by collectively voting on a scale from 1 to 10 for each index (severity, occurrence and no detection). The failure modes were prioritised according to the risk priority number (RPN), which is the product of the three indices. Finally, an action plan to control the highest RPN failure modes was developed.ResultsWe identified a total of 90 failure modes. The RPN ranged from 3 to 630. The rounded mean±SD was 108±60. The failure modes were considered ‘critical’ (n=31) for RPN ≥108, ‘to control’ (n=11) for 60