Proceedings of the 2018 IISE Annual Conference K.

Barker, D. Berry, C. Rainwater, eds.

The Effect of Poka-Yoke Implementation On Intravenous

Medication Error In Hospital Inpatient Pharmacy

Sasan Torabzadeh Khorasani and Ramyar Feizi

Texas Tech University
Lubbock, Texas

Hamid Tohidi
South Tehran Azad University
Tehran, Iran

Abstract

Pharmaceutical products are one of the critical elements of the healthcare industry because of the significant role they
play in the rising costs of this sector. One of the principal contributors to such costs is intravenous medication error in
hospital inpatient pharmacies. With regards to intravenous drugs, error is mainly related to preparation and
administration. Lean thinking has been utilized in healthcare for the elimination of error and waste. One reason for
significant drug error in hospitals is staff errors while working. Poka-yoke is a lean methodology which prevents staff
members from making errors by creating a visual or signal to show a characteristic state. In this work, the effect of
poka-yoke on errors related to intravenous medications in a case study is examined. Then, after detecting them,
recommendations are made to prevent those which can lead to cost and trauma.

Keywords
Error, Intravenous Medication Error, Human Error Prevention, Hospital Inpatient Pharmacy, Poka-Yoke, Cost

1. Introduction
It’s part of human nature to make mistakes, but it is also part of their nature to come up with solutions to prevent these
errors. It’s obvious preventing human errors has many benefits as it leads to increasing quality, safety and productivity
as well as reducing cost, waste and time. The idea of applying (human) error prevention techniques to industrial and
organizational processes is referred to as “poke-yoke”. Poka-yoke is the Japanese equivalent of “mistake-proofing”
which was first introduced by Shigeo Shingo in the 1960s to prevent human errors in industrial activities. Poka-yoke
aims to eliminate defects at the source by designing processes so that mistakes can be immediately detected and
corrected [1].

One of the crucial types of error which causes a significant source of public health concern is medical errors. Medical
errors are defined as the problems that occur while providing healthcare which lead to failure to complete a planned
action as intended or using a wrong action plan to achieve a goal. Such problems include improper transfusion, patient
identification errors and adverse drug events [2].

Kohn, et. al, published a report on the effect of medical errors in late 1999 in order to draw attention to the astounding
amount of cost and the number of lives lost attributed to medical errors. From two major studies, they estimated that
at least 44,000 patients and nearly 98,000 people died in hospital annually as a result of preventable medical errors. In
addition, they estimated that medical errors that could have been prevented resulted in total costs of at least $17 billion
and almost $29 billion per year in hospitals across the United States. With regards to medication errors (which is one
of the various forms of medical errors), they were estimated to lead to the death of 7,000 people [2]. The occurrence
of these errors included all phases of drug-use process such as ordering, transcribing, dispensing, and administration
 Khorasani, Feizi, Tohidi
[3]. Thus, the processes associated with medication errors provide an example where implementing human error
prevention will yield better performance [2].

In recent years, many quality and safety initiatives have been implemented to prevent medication errors. For instance,
Radley, et. al, showed that using computerized physician order entry systems yielded a 48% decrease in the likelihood
of medication errors in settings where inpatient acute-care was provided [4]. The Agency for Healthcare Research and
Quality provided a guide for reducing errors during the "administration" stage using bar-coded medication
administration. This technology helps users to ensure that medications are paired with the right patient, administered
at the right dose, given at the right route, and at the right time [3]. Also, some steps have been taken to reduce errors
due to fatigue, haste, negligence, and lack of experience [5].

More specifically and aligned with the subject of this work, one of the important types of medication errors identified
in hospitals which can lead to significant harm is related to intravenous (IV) medication. Over the past few decades,
there has been many of several hundred incidents reported by FDA involving IV pumps which have led to patient
deaths [6]. Medications injected into intravenous (IV) route expedite drug delivery to the body. Therapies involving
IV are a complex process as they need proper drug preparation before administration to patients. Errors can cause
harmful clinical consequences when it comes to intravenously administering medications at any stage. These stages
include preparation, dispensing and administration of these drugs [7]. Therefore, it’s important to explore what factors
influence the occurrence of intravenous medication errors in hospitals.

A number of studies have been conducted to determine the errors which occur in IV medication preparation and
administration. They analyzed the associated causes and the strategies to reduce those errors. Taxis & Barber
determined the incidence, clinical significance, and the stages of medication errors in the preparation and
administration phases of intravenous drugs as shown in Table 1. They found that the rate of errors was high and
concluded that a combination of various strategies such as utilizing technology for administration, training and
reducing the risks and mistakes in preparation steps would have the greatest effect on decreasing errors [8, 9]. In
another study, the main finding was that errors like delivering the wrong drug, in most cases occurred during drug
administration during the morning hours. This was probably a result of time constraint for preparation and
administration of the drugs in the morning due to the need for more nursing interventions [7]. Furthermore, Ong, et.
al, recommended that knowledge, training and design should be incorporated when it came to reducing a high rate of
IV medication errors in terms of preparation and administration in their observational study [7].

Table 1: Errors At Each Stage of Intravenous Drug Preparation and Administration [8, 9]
Stage Type of Error
1 Error in receiving medication
2 Error in receiving diluent
3 Error in reconstituting medication and diluent
4 Error in verifying the identity of patient
5 Error in checking for the allergies of patient
6 Error in checking the passage of medication administration
7 Error in checking the dose of medication
8 Error in evaluating patency of peripheral venous catheter
9 Error in removing air from syringe
10 Error in administering medication
11 Error in removing peripheral venous catheter
12 Error in signing the chart of prescription
13 Error in omitting

2. Methodology
A case study was designed based on the observations of a hospital in West Texas to act as a means of preventing
intravenous medications errors before they occur. To this end, this work provides an observation-based approach to
analyzing the aforementioned case study. This approach aims to identify errors related to IV drugs and thereby reduce
them by employing human error prevention (poka-yoke) techniques.
 Khorasani, Feizi, Tohidi

2.1 Case Study

Inpatient pharmacy X consists of the following stages and activities through which IV medications flow:
• Cleaning room: The room for preparing IV drugs, where sanitization and injection into IV drugs are
performed.
• Pharmacist office: The room where IV medications orders are controlled and verified by pharmacists.
• Medication room: IV medications are put and kept in Pyxis automated medication dispensing system (which
is a computer-controlled machine for decentralized storage, dispensing and tracking of medications as shown
in Figure 1) for administration in patient room [10].
• Patient room: Nursing staff picks up IV drugs in medication room and administers them in patient room.

Figure 1: BD Pyxis MedStation System [11]

2.2 Study Site

To describe the study site in more details, after practicing hygiene (hand-washing and wearing lab coat), nursing staff
starts sanitizing drugs using alcohol, then injects them into IV bags at a certain dose as required and next waits to send
IV drugs ordered by pharmacists (the related online computer software to record information gets automatically
updated at this stage). Afterwards, pharmacy staff starts verifying the orders after receiving them and after that
technicians start labelling IV medications (the information on the labels contains expiration date, patient’s name,
dosage, order number and drug code). Once they are done labelling, they start to put them on the shelves which are
for the IV drugs that were prepared on both a make to stock and a make to delivery basis. At a later stage, nursing staff
enters the medication room and starts searching for needed IV drugs by looking at their checklists. Next, they pick up
the ones that were prepared on an order to delivery basis and put them in a cart for administration in patient room. Or
sometimes they enter the medication room, turn on Pyxis MedStation system and begin putting IV medications which
were prepared on an order to stock basis in Pyxis MedStation system (the IV drugs status gets updated) as storage for
later administrations. Finally, they either proceed to administer IV drugs or hang them until the time of administration
in patient room. Also, it’s worth noting that nursing staff updates the status of IV drugs right before and after
administration in the related online computer software. A flowchart of IV drugs in the inpatient pharmacy is shown in
Figure 2.
 Khorasani, Feizi, Tohidi

3. Discussion
In the case study explained above, three errors related to IV medications were identified. This section provides a
number of recommendations to correct those errors as follows. Also, a summary of the errors and recommendations
is presented in Table 2.

3.1 Equipment collision

3.1.1 Error: While IV medications are carried in carts by nursing staff from medication room to patient room, it is
very likely that the carts containing IV drugs will collide with other staff members’ medical equipment. This potential
collision, in turn, can lead to damaging and therefore wasting IV drugs (in addition to harming medical equipment and
other medications).
3.1.2 Recommendation: This error can be prevented by creating more space for hospital employees so that they have
a wider range of motion when carrying IV medications and medical devices in the hospital setting to avoid potential
collisions. In addition, it’s recommended that collision detection systems be used to warn and, in some cases, to lock
if they sense that a collision is about to happen [11]. This way, neither the staff, IV drugs nor other medical devices
are harmed and the costs of the errors are proactively reduced.

Sanitize Inject drugs

drugs into IV bags
Cleaning Room

No?
Pharmacist Office Verif Out of scope
y of this paper
Yes?

Make to
Make to delivery
Label IV Place them on drugs
drugs the shelves stock or to
Medication Room delivery?

Put in Pyxis Make to stock

System Carry IV drugs to
patient room

Administer IV
Patient Room
drugs to patients

Figure 2: IV Medications Flowchart in the Inpatient Pharmacy

3.2 Wrong data Entry

3.2.1 Error: When it comes to administration in patient room, nursing staff makes some unnecessary movements
during the administration process. To clarify, before they enter the patient room, they walk towards a computer behind
it to update the status of IV drug, then return to patient room, administer IV drug to patient, and finally walk back
 Khorasani, Feizi, Tohidi
towards the computer again to finish updating IV drug status. These additional movements can lower nursing staff’s
concentration, attention and therefore cause them to make errors such as entering wrong data/information related to
IV drugs into the computer.
3.2.2 Recommendation: These unnecessary back and forth movements can be eliminated by using a portable digital
device instead of the computer behind the patient room. This, in turn, leads to preventing nursing staff from getting
distracted caused by unnecessary back and forth movements. As a result, being less distracted and less hurried can
help prevent nursing staff from making errors such as entering wrong data and information related to IV drugs into
the hospital online databases. Furthermore, utilizing suitable portable digital devices will expedite the overall service
delivery by shortening the administration time resulting from removing non-value added activities.
3.3 Administering wrong IV medication
3.3.1 Error As a rule in the hospital inpatient pharmacy, IV medications should be picked up for administration in
patient room on a FIFO (first-in, first-out) basis. The problem with this rule is that sometimes the IV drugs which were
prepared recently for administration might get confused with the first (older) ones at the time of pick-up from the
shelves (in medication room). One reason for this problem could be simply error in placing IV drugs by technicians
(misplacement). Another reason could be that since the IV medications prepared recently are placed in front of the old
ones (on the shelves), it is very likely that nursing staff not pick up the oldest IV medication (the first one at the very
back). Instead, for instance, it’s possible that they pick up the fourth oldest one because the old(er) IV drugs might not
be visible. This mistake; that is, picking up the new IV drugs instead of the first (old) ones for administration can lead
to the expiration, waste and therefore disposal of the initial IV medications.
3.3.2 Recommendation: In this case, a lack of adequate drug information such as improper sequencing can cause
medication errors (inadvertent mix-ups). In order to prevent such errors, it is recommended to implement a sequential
numbering strategy for IV drugs so that nursing staff not mistake the new ones for the old ones. To this end, it’s
suggested that a number of labels containing sequential numbers/codes in either ascending or descending order be
printed. Also, it’s worth regularly keeping the storage area well-organized to discard any IV medications that have
expired and to increase visibility [12].

Table 2: Errors and Recommendation for the Hospital Inpatient Pharmacy

Error Recommendation

Equipment collision • Creating more space for the hospital staff

• Using collision detection systems

Wrong data entry • Using a portable digital device

Administrating wrong IV medication • Implementing a sequential numbering strategy
• Keeping the storage area well-organized

4. Conclusion
The goal of applying lean tools in hospitals is to eliminate waste which makes hospitals incur a high amount of cost
[13]. Among various types of waste in hospitals, drug waste is one of the major sources of cost [14]. Since human
errors are made in activities related to intravenous medications, preventing them using poka-yoke can result in
significant savings for hospitals. The case study in this paper showed that human errors in healthcare systems are a
reality and therefore more attention should be paid to promote patient safety and reduce related costs. The
recommendations provided in this work can be established as guidelines to help healthcare practitioners avoid making
similar errors and understand the potential benefits of implementing poka-yoke.

5. Future work
This study revealed a potential source of improvement, although its recommendations have not been applied to the
subject of the paper yet. Therefore, future research should be conducted to validate the feasibility of the study in a
field setting by comparing the results of the current situation and those of implementing the recommendations.
Moreover, since implementing lean tools in a real-world scenario involves encountering some difficulties, the practical
challenges when applying the ideas in this paper should be identified.
 Khorasani, Feizi, Tohidi

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