St Patrick's Mental Health Services, Dublin, Ireland.
J Nurs Care Qual. 2020 Oct/Dec;35(4):E58-E62. doi: 10.1097/NCQ.0000000000000473.
Medication errors are potentially avoidable incidents that can lead to harm. Medications are often administered under challenging conditions, which creates opportunities for distractions and interruptions.
The aim of this study was to reduce the number of interruptions and distractions experienced by nurses during the medication administration process.
A Lean approach was used to value stream map the process, devise solutions, and measure the impact of the change.
Sources of distraction and interruption were identified. Through collaboration the medication administration process was standardized, and a purpose-built medication administration room was developed. Frequency of interruptions and distractions from all sources was reduced.
Value stream mapping the process enabled the identification of non-value-added activities that were threats to the integrity of the process. Standardizing the medication administration process and creating a safe space to facilitate the process successfully reduced interruptions and distractions from all sources.
用药错误是潜在的可预防事件，可能导致伤害。药物经常在具有挑战性的条件下给予，这为分心和中断创造了机会。
本研究旨在减少护士在给药过程中经历的中断和分心次数。
采用精益方法对流程进行价值流映射，设计解决方案，并衡量变更的影响。
确定了分心和干扰的来源。通过协作，对给药流程进行了标准化，并开发了一个专用的给药室。所有来源的中断和干扰的频率都降低了。
对流程进行价值流映射使我们能够识别对流程完整性构成威胁的非增值活动。通过标准化给药流程并创建一个安全的空间来促进该流程，成功减少了来自所有来源的中断和干扰。
