Medication error

Medication error

Force Field Analysis

-Technique for evaluating forces for and against change.

-Figure 2_Force_Field indicates equal driving and restraining forces.

-Implementing computerization has a chance for success but will be challenging.

Slide

Potential Solutions

Objectives

-System-related causes addressed with computerized technology.

-Proposed solutions: physician order entry, automated dispensing, electronic health records.

-Implementation changes include online prescriptions, data entry elimination, drug dispensing robots, bar-coded medication administration

• Perform root cause analysis

• Identify possible solution

• Make a force field analysis

• Identify common deliverables

• Measuring overall project performance

• Identifying process improvement tool

• Avoiding barriers to process improvement

Root Cause Analysis

-Fishbone diagram used to identify causes.

-Six main potential causes: prescribing error, expired medication, transcription errors, dispensing errors, administration errors, incorrect patient information.

-Branches include poor training, communication, system issues, inventory control, scheduling, workload, and data entry.

Deliverables

Introduction

-Tangible outcomes: reports, changing processes, increased satisfaction, quality, financial and operative performance improvements.

-Faster reports with interconnected database from computerization.

refrences

-Medication errors are common and costly, harming 1.5 million annually with $3.5 billion in extra medical costs.

-Result in death, hospitalization, disability, or birth defects.

Center for Drug Evaluation and Research. (n.d.). Working to reduce medication errors. U.S. Food and Drug Administration. Retrieved November 2, 2022, from https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors#:~:text=A%20medication%20error%20is%20defined,Medication%20Error%20Reporting%20and%20Prevention.

J;, F. A. C. H. T. F. (n.d.). Technology utilization to prevent medication errors. Current drug safety. Retrieved November 2, 2022, from https://pubmed.ncbi.nlm.nih.gov/20210714/

Medication errors. AMCP.org. (n.d.). Retrieved November 2, 2022, from https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors

Medication errors. AMCP.org. (n.d.). Retrieved November 2, 2022, from https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors

Y;, T. R. A. V. R. S. A. S. (n.d.). Medication dispensing errors and prevention. National Center for Biotechnology Information. Retrieved November 8, 2022, from https://pubmed.ncbi.nlm.nih.gov/30085607/

Agrawal, A. (2009, June). Medication errors: Prevention using Information Technology Systems. British journal of clinical pharmacology. Retrieved November 8, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723209/

Barriers to Process Improvement

Measuring Overall Project Performance

-Main barrier is resistance to change.

-Techniques to reduce resistance: partnering, thinking systematically, effective communication, obtaining approval.

-Key metrics: capacity, utilization, throughput time, rate, cycle time, wait time, work-in-process, value-added time, defects/errors.

-Computerization improves efficiency and effectiveness.

Conclusion

Process Improvement Tools

Thank you for listening!

Any questions?

-Comprehensive plan to address medication errors.

-Emphasis on technology, process changes, and stakeholder engagement.

-Anticipating challenges and employing effective strategies for success

-Techniques/tools for efficiency: eliminate non-value-adding activities, combine related tasks, parallel processing, critical path, information feedback, real-time control, quality at the source, identify best practices.

Logo