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六西格玛在电子药物管理记录(EDAR)系统中管理医疗差错的有效性。

Effectiveness of Six Sigma in Managing Medical Errors in the Electronic Drug Administration Record (EDAR) System.

作者信息

Ashgar Duaa A, Alotaibi Noot M, Al-Shahrani Saad M, Almanea Sarah, Almulhim Abdulaziz S, Alharbi Alsayed, Alhudaithi Nourah, Attia Ameera, Alghamdi Yasser A, Aljabri Duaa

机构信息

Continuous Quality Improvement and Patient Safety Administration Department, Armed Forces Hospital, Dhahran, SAU.

Pharmaceutical Department, Armed Forces Hospital, Dhahran, SAU.

出版信息

Cureus. 2025 May 26;17(5):e84864. doi: 10.7759/cureus.84864. eCollection 2025 May.

Abstract

INTRODUCTION

Medication errors can occur at any stage of the medication process, including prescribing, preparing, dispensing, or administering the medication by nurses. Any of these medication errors will impact patient safety and healthcare quality.

AIM

This study aimed to evaluate the effectiveness of the Six Sigma methodology in reducing medication errors within the Electronic Drug Administration Record (EDAR) system at the Armed Forces Hospital in Dhahran, Saudi Arabia.

METHODS

An assessment and the key elements of the Institute for Safe Medication Practices for medication use system were applied to the medication system to identify our pain points. A multidisciplinary team utilized the Six Sigma methodology following the phases of Define, Measure, Analyze, Improve, and Control framework over a 12-month period. Before intervention, data on prescribing errors were collected from the incident report system and compared retrospectively to all inpatient prescriptions from the EDAR pharmacy system. Prescribing errors analysis revealed a baseline error rate set at 2.1%. Key performance indicators were established to measure the effectiveness of implemented interventions.

RESULTS

Implementing targeted interventions resulted in a significant reduction in inpatient prescribing errors, achieving a new error rate of 1.3% and surpassing the initial target of ≤1.9%. The observed errors decreased from 2.1% to 1.3%, and the Sigma level improvement from 3.5 to 3.7 indicates a substantial enhancement in process performance, suggesting a true impact of the intervention. The defects per million opportunities improved from 20,532 to 13,760, reflecting a shift in the Sigma level from 3.5 to 3.7. Feedback from stakeholders indicated improved communication and user satisfaction with the EDAR system.

CONCLUSION

The study demonstrates that Six Sigma methodology effectively reduces medication errors and enhances patient safety within healthcare settings. Continued investment in optimizing pharmacy systems and fostering a culture of safety is crucial for sustaining these improvements and advancing the quality of patient care.

摘要

引言

用药错误可能发生在用药过程的任何阶段,包括开处方、调配、发药或护士给药。这些用药错误中的任何一个都会影响患者安全和医疗质量。

目的

本研究旨在评估六西格玛方法在沙特阿拉伯达兰武装部队医院的电子药物管理记录(EDAR)系统中减少用药错误的有效性。

方法

对用药系统应用安全用药实践研究所用药系统的评估和关键要素,以确定我们的痛点。一个多学科团队在12个月的时间里按照定义、测量、分析、改进和控制框架的阶段运用六西格玛方法。在干预前,从事件报告系统收集开处方错误的数据,并与EDAR药房系统的所有住院处方进行回顾性比较。开处方错误分析显示基线错误率设定为2.1%。建立关键绩效指标以衡量实施干预措施的有效性。

结果

实施针对性干预措施后,住院患者开处方错误显著减少,新的错误率达到1.3%,超过了≤1.9%的初始目标。观察到的错误率从2.1%降至1.3%,西格玛水平从3.5提高到3.7表明过程性能有了实质性提高,表明干预产生了真正的影响。百万机会缺陷数从20532提高到13760,反映了西格玛水平从3.5提高到3.7。利益相关者的反馈表明,对EDAR系统的沟通和用户满意度有所提高。

结论

该研究表明,六西格玛方法能有效减少医疗环境中的用药错误并提高患者安全性。持续投资优化药房系统并培养安全文化对于维持这些改进和提高患者护理质量至关重要。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/b5e3/12198939/57936dbcc52e/cureus-0017-00000084864-i01.jpg

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