Content area
Full Text
Among Healthcare errors, medication errors, including those made in prescriptions, pharmacy dispensing, handling by staff and handling by the patient in self-medicating situations, pose the most serious threat.
Interested in quality management in several areas, management at a mid-sized hospital (which chooses to be anonymous) approved a project using lean Six Sigma to determine what changes in policy and practices might be necessary to significantly reduce these errors.
Project Team
The group tasked with making this determination was set up in two tiers: a project team overseen by a steering committee.
The steering committee consisted of members of upper management and heads of functional departments. This committee appointed employees with relevant daily floor level experience in various associated processes as members of the project team. Specifically, these individuals were involved in the processes of prescription transcription, order filling and all other stops influencing the error rate in the medication administration records (MARs).
In addition, the project team included individuals who could recommend and implement interventions to error reduction. The project team periodically reported to the steering committee.
Defining the Problem
The process of medication administration at a hospital involves six steps:
1. Selecting and procuring.
2. Storing.
3. Ordering and transcribing.
4. Preparing and dispensing.
5. Administering the medication.
6. Monitoring medication effects.
Due to time constraints, the steering committee defined the most urgent problem as the unknown error rate in the hospital MAR. The scope of the project was to concentrate on the medication order entry (OE) process. The project team charter aimed to investigate a process to dramatically reduce MAR errors by a factor of about 1,000 by the end of the project's five-month duration.
Measuring the Baseline And Tracking Errors
Prior to the formation of this project team, the hospital's quality improvement department had mapped the pharmacy OE and the nursing MAR transcription processes. The project team reviewed and verified the process maps against the current practices and sequence of operations.
The team reviewed the errors observed in February in the pharmacy OE process. An effort was then made to more rigorously define these errors and establish the criteria for cataloging them to aid in root cause analysis and achieve better consistency in error tabulation. This attempt minimized subjectivity and thus achieved...