目的利用精益六西格玛(LSS)和失效模型与效应分析(FMEA)预防中国教学医院的分配错误。
收集了医院药剂师向国际合理用药网络中国核心集团报告的用药错误(MEs)。按照LSS方法,数据分析是根据定义构建的,measure,分析,改进,和控制(DMAIC)阶段,和典型的LSS工具(帕累托图,头脑风暴会议)用于确定导致分配错误的风险因素。FMEA用于生成ME事件的风险优先级编号(RPN),通过定量分析失败的影响,确定了针对错误预防策略的关键药物。最后,实施预防MES的纠正措施并监测疗效.
在实施该计划之前,从第1年到第6年,共报告了603例配药错误,平均发生率为每10000份药物订单0.33例,这些年之间没有发现差异(P=.9424)。位置也没有区别,错误类型,促成因素,考虑了原因分类。然后我们确定了分配错误背后的真正原因,共有67种药物针对特定的错误预防策略.干预一年后,在以下方面取得了进展:与前几年相比,分配错误的发生率显着下降(0.19,P=.007)。同时,门诊药房配药差错发生率(0.04,P=.0008),初级药剂师(0.15,P=0.0258),LASA药物(0.06,P=.0319),以及基于记忆的错误显着减少(0.03,P=.0191)。
LSS和FMEA工具的组合可以成为帮助减少药房分配中的ME的有效方法。
To utilize lean six sigma (LSS) and failure model and effect analysis (FMEA) to prevent dispensing errors in a Chinese teaching hospital.
Medication errors (MEs) reported to the
China Core Group of the international network for the rational use of drugs (INRUD) by pharmacists at the hospital were collected. Following LSS methodology, the data analysis was structured according to define, measure, analyse, improve, and control (DMAIC) phases, and typical LSS tools (Pareto diagrams, brainstorming sessions) were used to determine the risk factors leading to dispensing errors. FMEA was applied to generate the risk priority numbers (RPNs) of MEs events, and key medications targeted for error prevention strategies were identified through quantitative analysis of the impacts of failure. Finally, corrective measures to prevent MEs were implemented and monitored for efficacy.
Before the implementation of this programme, a total of 603 cases of dispensing errors were reported from the Year 1 to Year 6, reaching an average rate of incidence of 0.33 cases per 10 000 medication orders delivered, and no difference was found between these years (P = .9424). There was also no difference as location, error type, contributing factors, cause classification were considered. We then determined the real cause behind dispensing errors, and a total of 67 medications were targeted for specific error prevention strategies. One year after intervention, progress had been achieved in the following aspects: the incidence rate of dispensing errors was significantly decreased compared with the previous years (0.19, P = .007). Simultaneously, the incidence rate of dispensing errors occurred in outpatient pharmacy (0.04, P = .0008), with junior pharmacists (0.15, P = .0258), with LASA medications (0.06, P = .0319), as well as with memory-based errors were significantly decreased (0.03, P = .0191).
The combination of LSS and the FMEA tool can be an efficient approach for helping reduce MEs in pharmacy dispensing.