Lesson 2 Assignment: Using DMAIC Tables

Kayla Yun

UW- Parkside

HCA 740: Healthcare Operations and Project Management

Professor Gordon

September 18, 2021

Topic: Medication Administration Errors

DMAIC Insert your information below

Stage

Define In the pharmacy, medication administration errors are frequent, yet they may have serious
implications, ranging from sickness to death. Unintentional patient injury is preventable,
and there are steps you can do to ensure it doesn't happen. To improve patient safety, the
aim is to decrease medication errors in pharmacies by 50%. The patient getting the
completed prescription from the pharmacist is the external customer in this procedure
(Alkuwaiti, 2016). The research team must next go through the findings of the patient
satisfaction survey, as well as comments from respondents about lengthy wait times in
the pharmacy, which may be due to rework caused by drug errors in the pharmacy
(Alkuwaiti, 2016). This is used to evaluate consumers by identifying whether products
satisfy, delight, or dissatisfy them (ASQ, n.d.). A survey must also be sent to the
pharmacy employees to evaluate the voice of the internal consumer (Alkuwaiti, 2016).
The research team must assess the prescription dispensing process to give an overview of
the whole process, beginning with the customer, and ending with the customer, and
determining what is needed to satisfy consumer requirements.
Measure If you want to evaluate the performance of your process, you need to develop a data
collection sheet that will allow you to collect baseline data in the outpatient pharmacy
and determine what types of medication mistakes are occurring and at what stage of the
prescription dispensing process the medication errors are occurring (Alkuwaiti, 2016)
During the baseline data collecting procedure, the process step where the mistake
occurred, the kind of error, the drug class, and whether or not the prescription was for a
compounded medicine are all recorded as part of the process (Alkuwaiti, 2016). In
addition, a capacity analysis will be carried out to determine a process's ability to meet
requirements, and a Pareto chart will be used to determine the frequency of drug
administration problems or their underlying factors. Defects per unit (number of defects /
total number of units), Defects per opportunity (DPO) (number of defects / (number of
units x number of defect chances per unit), and Proportion defective (p) (number of faulty
units / total number of units) may all be determined by conducting these processes
(Henshall, 2020).
Analyze It is essential to examine the procedure to identify and correct the cause of medication
errors. A root cause analysis should be performed to analyze the process and identify the
underlying reasons of the cause of the drug administration errors. This will reveal cases
and may reveal that the bulk of the mistakes happened during the data input stage. All
these different types of data entry errors are often caused by improperly entering
information into the computer system. A Failure Mode and Effects Analysis (FMEA)
should then be performed to identify the process's main hazards (Alkuwaiti, 2016). It
evaluates potential product, service, and process failures based on previous experience
with the system and assist the research team in prioritizing hazards and developing action
plans to mitigate them (ASQ, n.d.). The FMEA focuses on the kinds of mistakes that may
occur throughout the prescription distribution process, and the team used it to evaluate
possible failures and assign each one a risk priority number using a grading system
(Alkuwaiti, 2016). Following the completion of the FMEA, it may be determined that the
 data input process step requires improvement, and a suitable improvement plan must be
developed (Alkuwaiti, 2016).
Improve  Once the underlying root causes have been identified and addressed, it is possible to
enhance process performance. For improvement, the design of an experiment to address
problems emerging from complex processes or systems with numerous factors
influencing the outcome, and no method to isolate one feature or variable from another is
essential (ASQ, n.d.). For high-quality improvements, one is then able to test and observe
what works and what does not. Action plans may then be created and implemented in
accordance with the results of the FMEA. The implementation of additional patient
identifiers, the availability of prescription label barcode scanning where entry workers are
provided with the necessary training to use it, the establishment of acceptable taut time,
and, most importantly, the development of a standardized and effective training program
based on previous medication mistake experiences and lessons learned are all examples
of actions plans for improvement in the pharmacy (Alkuwaiti, 2016).
Control To maintain the improvements made in the pharmacy prescription dispensing process, an
overall control plan is put in place to record what is required to retain the enhanced
process at its current level. The pharmacy manager supervisor and pharmacy personnel
will manage the control plan to ensure that the improvements achieved are maintained
and hold accountability for all staff Alkuwaiti, 2016). The new process may be monitored
to ensure its long-term viability using this management strategy (Alkuwaiti, 2016). To
make mistakes impossible or quickly observable, mistake-proofing and the use of the 5S
approach is also utilized. This is where modifications to the prescription distribution
procedure can be made to avoid data input mistakes (Alkuwaiti, 2016). The usage of
electronic prescriptions is a mistake-proofing technique that helps to reduce mistakes at
the time of data input in the pharmacy dispensing process (Alkuwaiti, 2016). Errors such
as the use of the incorrect medication or dosage might be avoided if this was done
(Alkuwaiti, 2016). Overall, If you follow these steps, you are likely to decrease
medication errors in pharmacies by 50% and enhance patient safety.

References
Alkuwaiti, Ahmed. (2016). Application of Six Sigma Methodology to Reduce Medication Errors

in the Outpatient Pharmacy Unit: A Case Study from the King Fahd University Hospital,

Saudi Arabia. International Journal for Quality Research. 10. 267-278.

10.18421/IJQR10.02-03.

Henshall, A. (2020, November 26). DMAIC: The Complete guide to Lean Six sigma in 5 key

steps: Process Street: CHECKLIST, workflow and Sop software. Process Street.

Retrieved September 18, 2021, from https://www.process.st/dmaic/.

The define, measure, analyze, improve, control (dmaic) process. ASQ. (n.d.). Retrieved

September 17, 2021, from https://asq.org/quality-resources/dmaic.