Pharmacy Department, Tallaght Hospital, Belgard Road, Tallaght, Dublin 24, Ireland.
BMJ Qual Saf. 2012 Dec;21(12):1042-51. doi: 10.1136/bmjqs-2012-000824. Epub 2012 Aug 7.
Safe, effective therapy with the antimicrobial gentamicin requires good practice in dose selection and monitoring of serum levels. Suboptimal therapy occurs with breakdown in the process of drug dosing, serum blood sampling, laboratory processing and level interpretation. Unintentional underdosing may result. This improvement effort aimed to optimise this process in an academic teaching hospital using Six Sigma process improvement methodology.
A multidisciplinary project team was formed. Process measures considered critical to quality were defined, and baseline practice was examined through process mapping and audit. Root cause analysis informed improvement measures. These included a new dosing and monitoring schedule, and standardised assay sampling and drug administration timing which maximised local capabilities. Three iterations of the improvement cycle were conducted over a 24-month period.
The attainment of serum level sampling in the required time window improved by 85% (p≤0.0001). A 66% improvement in accuracy of dosing was observed (p≤0.0001). Unnecessary dose omission while awaiting level results and inadvertent disruption to therapy due to dosing and monitoring process breakdown were eliminated. Average daily dose administered increased from 3.39 mg/kg to 4.78 mg/kg/day.
Using Six Sigma methodology enhanced gentamicin usage process performance. Local process related factors may adversely affect adherence to practice guidelines for gentamicin, a drug which is complex to use. It is vital to adapt dosing guidance and monitoring requirements so that they are capable of being implemented in the clinical environment as a matter of routine. Improvement may be achieved through a structured localised approach with multidisciplinary stakeholder involvement.
安全、有效的抗菌药物庆大霉素治疗需要在剂量选择和监测血清水平方面有良好的实践。药物剂量、血清采血、实验室处理和水平解读过程中的任何一个环节出现问题，都可能导致治疗效果不理想。可能会出现用药不足的情况。本改进项目旨在使用六西格玛（Six Sigma）流程改进方法，优化一家学术教学医院的这一流程。
成立了一个多学科项目团队。确定了对质量至关重要的流程措施，并通过流程映射和审核检查了基线实践情况。根本原因分析为改进措施提供了信息。这些措施包括新的剂量和监测计划，以及标准化的检测采样和药物管理时间，最大限度地利用了当地的能力。在 24 个月的时间里，进行了三轮改进循环。
在规定时间窗口内采集血清水平的目标实现率提高了 85%（p≤0.0001）。给药准确性提高了 66%（p≤0.0001）。避免了在等待检测结果时不必要的剂量遗漏，以及因剂量和监测过程中断而导致的治疗中断。平均日剂量从 3.39 毫克/公斤增加到 4.78 毫克/公斤/天。
使用六西格玛方法提高了庆大霉素使用流程的性能。与庆大霉素使用相关的当地流程因素可能会对遵守庆大霉素使用指南产生不利影响，因为这种药物的使用比较复杂。重要的是，要调整剂量指导和监测要求，以便能够将其作为常规在临床环境中实施。通过多学科利益相关者的参与，采取结构化的本地化方法，可以实现改进。
