Yousef Nadin, Yousef Farah
Researcher in Pharmaceutical Sciences and Medical Researches, Lattakia, Syria.
Ph.D. candidate in Pharmaceutical Sciences, Damascus University, Damascus, Syria.
BMC Health Serv Res. 2017 Sep 4;17(1):621. doi: 10.1186/s12913-017-2531-6.
Whereas one of the predominant causes of medication errors is a drug administration error, a previous study related to our investigations and reviews estimated that the incidences of medication errors constituted 6.7 out of 100 administrated medication doses. Therefore, we aimed by using six sigma approach to propose a way that reduces these errors to become less than 1 out of 100 administrated medication doses by improving healthcare professional education and clearer handwritten prescriptions.
The study was held in a General Government Hospital. First, we systematically studied the current medication use process. Second, we used six sigma approach by utilizing the five-step DMAIC process (Define, Measure, Analyze, Implement, Control) to find out the real reasons behind such errors. This was to figure out a useful solution to avoid medication error incidences in daily healthcare professional practice. Data sheet was used in Data tool and Pareto diagrams were used in Analyzing tool.
In our investigation, we reached out the real cause behind administrated medication errors. As Pareto diagrams used in our study showed that the fault percentage in administrated phase was 24.8%, while the percentage of errors related to prescribing phase was 42.8%, 1.7 folds. This means that the mistakes in prescribing phase, especially because of the poor handwritten prescriptions whose percentage in this phase was 17.6%, are responsible for the consequent) mistakes in this treatment process later on. Therefore, we proposed in this study an effective low cost strategy based on the behavior of healthcare workers as Guideline Recommendations to be followed by the physicians. This method can be a prior caution to decrease errors in prescribing phase which may lead to decrease the administrated medication error incidences to less than 1%.
This improvement way of behavior can be efficient to improve hand written prescriptions and decrease the consequent errors related to administrated medication doses to less than the global standard; as a result, it enhances patient safety. However, we hope other studies will be made later in hospitals to practically evaluate how much effective our proposed systematic strategy really is in comparison with other suggested remedies in this field.
用药错误的主要原因之一是给药错误,一项与我们的调查和综述相关的先前研究估计,用药错误的发生率为每100剂给药剂量中有6.7次。因此,我们旨在采用六西格玛方法,通过改善医护人员教育和使手写处方更清晰,提出一种将这些错误减少到每100剂给药剂量中少于1次的方法。
该研究在一家政府综合医院进行。首先,我们系统地研究了当前的用药流程。其次,我们采用六西格玛方法,利用五步DMAIC流程(定义、测量、分析、实施、控制)来找出此类错误背后的真正原因。这是为了找出一个有用的解决方案,以避免日常医护人员实践中的用药错误发生率。数据工具中使用了数据表,分析工具中使用了帕累托图。
在我们的调查中,我们找到了给药错误背后的真正原因。正如我们研究中使用的帕累托图所示,给药阶段的错误百分比为24.8%,而与处方阶段相关的错误百分比为42.8%,是前者的1.7倍。这意味着处方阶段的错误,尤其是由于手写处方不佳(该阶段此类错误的百分比为17.6%),导致了后续治疗过程中的错误。因此,我们在本研究中基于医护人员的行为提出了一种有效的低成本策略,作为医生应遵循的指南建议。这种方法可以作为一种预先防范措施,以减少处方阶段的错误,这可能会导致给药错误发生率降低至1%以下。
这种行为改善方式可以有效地改善手写处方,并将与给药剂量相关的后续错误降低至全球标准以下;因此,它提高了患者安全性。然而,我们希望以后能在医院进行其他研究,以实际评估我们提出的系统策略与该领域其他建议的补救措施相比究竟有多有效。