van der Sluijs Alexander F, van Slobbe-Bijlsma Eline R, Goossens Astrid, Vlaar Alexander Pj, Dongelmans Dave A
Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.
Department of Intensive Care Medicine, Tergooi Hospitals, Hilversum, The Netherlands.
SAGE Open Med. 2019 Jan 2;7:2050312118822629. doi: 10.1177/2050312118822629. eCollection 2019.
Medication errors occur frequently and may potentially harm patients. Administering medication with infusion pumps carries specific risks, which lead to incidents that affect patient safety.
Since previous attempts to reduce medication errors with infusion pumps failed in our intensive care unit, we chose the Lean approach to accomplish a 50% reduction of administration errors in 6 months. Besides improving quality of care and patient safety, we wanted to determine the effectiveness of Lean in healthcare.
We conducted a before-and-after observational study. After baseline measurement, a value stream map (a detailed process description, used in Lean) was made to identify important underlying causes of medication errors. These causes were discussed with intensive care unit staff during frequent stand-up sessions, resulting in small improvement cycles and bottom-up defined improvement measures. Pre-intervention and post-intervention measurements were performed to determine the impact of the improvement measures. Infusion pump syringes and related administration errors were measured during unannounced sequential audits.
Including the baseline measurement, 1748 syringes were examined. The percentage of errors concerning the administration of medication by infusion pumps decreased from 17.7% (95% confidence interval, 13.7-22.4; 55 errors in 310 syringes) to 2.3% (95% confidence interval, 1-4.6; 7 errors in 307 syringes) in 18 months (p < 0.0001).
The Lean approach proved to be helpful in reducing errors in the administration of medication with infusion pumps in a high complex intensive care environment.
用药错误频繁发生，可能对患者造成潜在伤害。使用输液泵给药存在特定风险，会引发影响患者安全的事件。
由于我们重症监护病房此前减少输液泵用药错误的尝试失败了，我们选择采用精益方法，在6个月内将给药错误减少50%。除了提高护理质量和患者安全外，我们还想确定精益方法在医疗保健中的有效性。
我们进行了一项前后观察性研究。在基线测量后，绘制了价值流图（精益中使用的详细流程描述），以确定用药错误的重要潜在原因。在频繁的站立会议期间与重症监护病房工作人员讨论这些原因，从而形成小的改进周期和自下而上确定的改进措施。进行干预前和干预后的测量，以确定改进措施的影响。在不预先通知的连续审计期间测量输液泵注射器及相关给药错误。
包括基线测量在内，共检查了1748个注射器。18个月内，输液泵给药错误的百分比从17.7%（95%置信区间，13.7 - 22.4；在310个注射器中有55个错误）降至2.3%（95%置信区间，1 - 4.6；在307个注射器中有7个错误）（p < 0.0001）。
在高度复杂的重症监护环境中，精益方法被证明有助于减少输液泵给药错误。
