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Understanding and reducing the medication delivery waste via systems mapping and analysis

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Abstract

The enormous gaps in the knowledge required to understand medication errors and their related costs (or wastes) in all hospital settings have become a growing national concern. Such gaps are often the major reasons causing risk for patient safety and creating waste to the hospital. However, medication delivery system cannot be successfully improved and implemented without a clear understanding of various process flows running around the entire hospital system. This paper presents a systems mapping and analysis method to help understand and reduce the medication delivery waste. The effectiveness of our method is illustrated by a case study that we conducted for the medication delivery process at Bozeman Deaconess Hospital, MT.

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References

  1. Bates D, Cullen D, Laird N, L et al (1995) Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 274:29–34

    Article  Google Scholar 

  2. Leape L, Bates D, Cullen D et al (1995) Systems analysis of adverse drug events. JAMA 274:35–43

    Article  Google Scholar 

  3. Barker K, Flynn E, Pepper G et al (2002) Medication errors observed in 36 health care facilities. Arch Intern Med 162:1897–1903

    Article  Google Scholar 

  4. Institute of Medicine (2006) Preventing Medication Errors. Institute of Medicine Report, Washington, D.C.

    Google Scholar 

  5. Eskew J, Jacobi J, Buss W et al (2002) Using innovative technologies to set new safety standards for the infusion of intravenous medications. Hosp Pharm 37:1179–1189

    Google Scholar 

  6. Hatcher I, Sullivan M, Hutchinson J et al (2004) An intravenous medication safety system: preventing high-risk medication errors at the point of care. J Nurs Adm 34:437–439

    Article  Google Scholar 

  7. Williams C, Maddox R (2005) Implementation of an i.v. medication safety system. Am J Health–Syst Pharm 62:530–536

    Google Scholar 

  8. Wilson K, Sullivan M (2004) Preventing medication errors with smart infusion technology. Am J Health–Syst Pharm 61:177–183

    Google Scholar 

  9. Kaushal R, Bates D, Landrigan C et al (2001) Medication errors and adverse drug events in pediatric inpatients. JAMA 285:2114–2120

    Article  Google Scholar 

  10. Ross L, Wallace J, Paton J (2000) Medication errors in a pediatric teaching hospital in the UK: five years operational experience. Arch Dis Child 83:492–497

    Article  Google Scholar 

  11. Vanerveen T (2005) Averting highest-risk errors is first priority. Patient Safety and Quality Healthcare 2:16–21

    Google Scholar 

  12. Thurman S, Williams M, Gaffney F (2004) Intravenous medication safety systems help prevent harm and career-ending mistakes. Nurs Manage (Suppl.):2–4

  13. Institute of Medicine (2001) Crossing the quality chasm: a new heath care system for the 21st century. Institute of Medicine Report, Washington, D.C.

    Google Scholar 

  14. Institute of Medicine (2005) Building a better delivery system: a new engineering/heath care partnership. Institute of Medicine Report, Washington, D.C.

    Google Scholar 

  15. Womack J, Jones D, Roos D (1990) The machine that changed the world: the story of lean production. Harper-Perennial, New York

    Google Scholar 

  16. Womack J, Jones D (1996) Lean Thinking. Simon & Schuster, New York

    Google Scholar 

  17. Liker J (1998) Becoming lean: inside stories of U.S. manufacturers. Productivity Press, Portland, OR

    Google Scholar 

  18. Monden Y (1993) Toyota Production System: An Integrated Approach to Just-In-Time. Second Edition, Industrial Engineering and Management Press, Norcross, GA

    Google Scholar 

  19. Rother M, Shook J (1998) Learning to see. The Lean Enterprise Institute, Inc., Brookline, MA

    Google Scholar 

  20. Thompson D, Wolf G, Spear S (2003) Driving improvement in patient care. J Nurs Adm 33:585–595

    Article  Google Scholar 

  21. Sobek D, Jimmerson C (2003) Applying the Toyota Production System to a hospital pharmacy. Industrial Engineering Research Conference, Portland, Oregon

    Google Scholar 

  22. Sobek D, Jimmerson C (2004) A3 reports: tool for process improvement. Industrial Engineering Research Conference, Houston, Texas

    Google Scholar 

  23. Jimmerson C, Weber D, Sobek D (2005) Reducing waste and errors: piloting lean principles at IHC. Joint Comm J Qual Saf 83:249–257

    Google Scholar 

  24. Spear J (2005) Fixing healthcare from the inside, today. Harvard Business Review 78–91

  25. Ghosh M, Sobek D (2007) Effective metaroutines for organizational problem solving, working paper

  26. Tucker A, Edmondson A (2002) Managing routine exception: a model of nurse problem solving behavior. Adv Health Care Manag 3:87–113

    Article  Google Scholar 

  27. Tucker A, Edmondson C (2003) Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev 45:55–72

    Google Scholar 

  28. Classen D, Pestonik S, Evans S et al (1991) Computerized surveillance of adverse drug events in hospital patients. JAMA 266:2847–2851

    Article  Google Scholar 

  29. Evans R, Pestotnik S, Classen D (1998) A computer-assisted management program for antibiotics and other anti-infective agents. N Engl J Med 338:232–238

    Article  Google Scholar 

  30. Garibaldi R (1998) Computers and the quality of care: a clinician’s perspective. N Engl J Med 338:259–260

    Article  Google Scholar 

  31. Bates D, Teich J, Lee J et al (1999) The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 6:313–321

    Google Scholar 

  32. Casalino L, Gillies S, Schmittdiel J, Bodenheimer T et al (2003) External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases JAMA 289:434–441

    Article  Google Scholar 

  33. Breslow M (2005) The eICU solution: a technology-enabled care paradigm for ICU performance, in: Building Better Delivery System. Institute of Medicine Report, Washington, D.C.

    Google Scholar 

  34. Clayton P (2005) Obstacles to the implementation and acceptance of electronic medical record system, in: Building Better Delivery System. Institute of Medicine Report, Washington, D.C.

    Google Scholar 

  35. National Patient Safety Partnership (1999) Healthcare Leaders Urge Adoption of Methods to Reduce Adverse Drug Events. News Release

  36. National Coordinating Council for Medication Error Reporting and Prevention (2005) Defining a Problem and Developing Solutions. NCCMERP

  37. Klein H, Isaacson J (2003) Making medication instructions usable. Ergon Des 11:7–11

    Google Scholar 

  38. Haberstroh C (1965) Organization, design and systems analysis in handbook of organizations. Rand McNally, Chicago

    Google Scholar 

  39. Reason J (1990) Human error. Cambridge University Press, Cambridge

    Google Scholar 

  40. Reason J (1994) Forward in human error in medicine. Lawrence Erlbaum Associates, Marilyn Sue Bogner, Hillsdale, NJ

    Google Scholar 

  41. American Society of Health-System Pharmacists (1996) Top-priority actions for preventing adverse drug events in hospitals, Recommendations of an expert panel. Am J Health–Syst Pharm 53:747–751

    Google Scholar 

  42. Flynn E, Barker K, Pepper G, Bates D et al (2002) Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health–Syst Pharm 59:436–446

    Google Scholar 

  43. Atkinson P, Hammersley M (1998) Ethnography and Participant Observation, in: Strategies of Qualitative Inquiry, ed. N. Denzin and S. Yvonna. Sage Publications

  44. Cook R, Woods D, Miller C (1998) Tale of two stories: contrasting views of patient safety. National Patient Safety Foundation, Chicago

    Google Scholar 

  45. Van Cott H (1994) Human errors: their causes and reductions in human error in medicine. Lawrence Erlbaum Associates, Marilyn Sue Bogner, Hillsdale, NJ

    Google Scholar 

  46. Gandhi T, Seger D, Bates D (2000) Identifying drug safety issues: from research to practice. Int J Qual Health Care 12:69–76

    Article  Google Scholar 

  47. Adair G (1984) The Hawthorne effect: a reconsideration of the methodological artifact. J Appl Psychol 69:334–345

    Article  Google Scholar 

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Correspondence to Shi-Jie (Gary) Chen.

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Mazur, L.M., Chen, SJ.(. Understanding and reducing the medication delivery waste via systems mapping and analysis. Health Care Manage Sci 11, 55–65 (2008). https://doi.org/10.1007/s10729-007-9024-9

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  • DOI: https://doi.org/10.1007/s10729-007-9024-9

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