Preventung Dispensing Errors Through Utilization Of Lean Six Sigma DMAIC Model

OBJECTIVE To explore how to use Lean Six Sigma DMAIC model to prevent dispensing errors in a hospital,reduce the occurrence of medical errors,improve the precision of medication dispensing and ensure the safety of patients and provide new experiences for further promoting pharmaceutical care.METHODS Data analysis was carried out according to DMAIC model of Lean Six Sigma--define,measure,analysis,improve and control.1.In the definition phase:determine the objectives and critical-to-quality of the quality improvement activity,determine the implementation committee of the activity,and define relevant issues.2.During the measure and analysis phase: historical medication errors data reported by the staff to the INRUD China Core Group clinical drug safety monitoring network were collected,and the dispensing errors data were extracted as historical data after review.Key factors leading to the occurrence of errors from the perspectives of location,initiator,error type,contributing factors and psychological classification were measured and analyzed with data analysis and pareto diagram tools.3.In the improve phase,apply the flow chart,brainstorm and cause-effect diagram tool to develop improvement measures.Meanwhile,apply the Failure model and effect analyze(FMEA)to generate the risk priority number of dispensing errors events.4.In the control phase :implement the strategy of preventing dispensing errors,and proactively collect dispensing errors reports during the one-year implementation of quality improvement activity.Evaluate the effects of quality improvement activity by comparing data before and after interventions.RESULTS By measuring and analyzing the six years' 603 cases of historical data,the key factors leading to the dispensing errors were obtained: the locations were outpatient pharmacy and internal medicine of inpatient pharmacy;the error initiator was the primary pharmacist;the error type was the wrong drug,wrong quantity and wrong strength;error factors were LASA,inadequate review and fatigue;psychology classification were action-based and memory-based errors.Finally,67 drugs with more than RPNs 4 were selected as the key targets of error prevention through FMEA risk assessment,and prevention strategies were developed for drug environment personnel and computer system.58 cases of dispensing errors were received after the one-year execution of the quality improvement activity,which was 49.50% less than the historical average.The improvement in dispensing errors from outpatient pharmacies was greatest: from an average of 52.19 cases per year to 13.00;errors caused by primary pharmacists decreased from 91.24 to 45.00 cases per year.Among the error types,the wrong strength decreased the most(66.59%),followed by the wrong drug(59.06%)and the wrong quantity(36.06%).Contributing factors: LASA,inadequate review and fatigue were reduced by 61.19%,52.99% and 21.25% respectively;psychological classification: the action-based and memory-based errors were reduced by 41.50% and 41.70% respectively.CONCLUSION There is a long way to go in the management of medication errors.Applying the LSS DMAIC model to preventing medication errors in the dispensing stage can significantly reduce the occurrence of medication errors,thus better ensuring patient safety.This provides a new method for medical manager to manage medication errors more effectively.