Six Sigma: “Using Six Sigma to Reduce Medication

Errors in a Home-Delivery Pharmacy Service

Kelompok 2:
1. Hirzie 02411640000
2. Muhammad Ilham Rinaldi 02411640000158
3. Rachmad Irvan S 02411640000166
4. Inggrita Putri Kusuma W 02411740000005
5. Rico Feryanto 02411740000007
6. Aprillia Indah S. 02411740000010
Background
• Medco Health Solutions, Inc. Conducted a
project to reduce medication errors in its
home-delivery service, which is composed
of eight prescription-processing
pharmacies, three dispensing pharmacies,
and six call-center pharmacies.
• The prescription-processing pharmacies
focus on evaluating the clinical and benefit
management aspects of prescriptions.
Activities include clarifying ambigously
written presciptions with physicians and
addressing potential drug drug related
problems.
• In the dispensing pharmacies, the
prescription products are retrived,
packaged, and sent to the patient
according to the approved prescription
order.
• Medco, uses the Six Sigma methodology
to reduce process variation, establish
procedures to monitor the effectiveness
of medication safety programs,
• In November 2001, Medco’s clinical
quality committee identified significant
process variation among the way the
pharmacies gathered data. In February
2002 senior management commissioned a
Six Sigma team.
• The team was charged with the mission of
reviewing the processes in the home-
delivery pharmacy that may lead to a
medication error and suggesting
strategies to improve the data collection
and medication-dispensing practices
• The team included experts from across the
company, including pharmacists, physicians,
nurses, epidemiologists, engineers and
many more.
• Their responsibilities included database
development, data collection and analysis,
data, display and “tollgate” presentations
• The entire Six Sigma team received
extensive training as either “green belts” or
“black belts”; the executive staff, or
“project sponsors,” were trained as “yellow
belts.” “master black belt” provided
direction and resource information to the
team through- out the project.
 Define Phase: Medication
Define Phase Error Definition
• A medication error is any preventable
event that may cause or lead to
inappropriate medication use or patient
harm while the medication is in the
control of the health care professional,
patient, or consumer.
• Dispensing Accuracy Rate : It’s based on the
number of patient self-reported potential
medication errors conveyed through the customer
service department
• Medication Error : preventable event that may
cause or lead to inappropriate medication use or
patient harm while the medication is in the control
of the health care professional, patient, or
consumer
• Define Phase: Process Flow Map
• Measure Phase : Database Construction
• Measure Phase : Error-Reporting Process
• Process Control Tools digunakan untuk • Kesalahan pemilihan obat
menampilkan data yang dikumpul kontributor terbesar (42%)
selama 5 bulan pertama • Dari kesalahan pemilihan
obat,35% dibuat meskipun resep
• Apotek pengolah resep bertanggung ditulis secara jelas,23% dari obat
jawab 96% dari ENCs sedangkan apotek yang terdengar mirip,dan 18%
terjadi karena kegagalan
yang meracik hanya 4% mengikuti SOP.
• Pemberi resep bertanggung jawab • SOP tidak konsisten diseluruh
secara langsung dari 2 % kesalahan yang organisasi, karena dikembangkan
dilaporkan. Pasien bertanggung jawab oleh masing-masing individu
farmasi
8% dari semua kesalahan yang
dilaporkan • Struktur pelaporan sebelumnya
didasarkan pada potensi tindakan
dari komisi yang berpotensi
menyebabkan kesalahan pada
pasien.
To reduce medication error, there are some improvement
activities that can be implemented: 45% 42% 35% 42%
Establishing a continous
Ensured that the local pharmacy SOPs were consistent 40%
with each other and aligned them with the corporate chart 35% 28% quality improvement process
30% 23% 22%
of standards 25% 18% to ensure that medication
Enhanced regular and ongoing education, awareness, and 20% 14% Before
training for pharmacists, specifically about commonly 15% 7% 8% errors are minimized is critical
10%
occurring medication errors 5% After
Initiated a procedure for developing, reviewing, and 0% to any health care
enhancing SALA alerts organization providing
Developed a compatibility chart for supplies for patients
with diabetes to increase the probability that the
medication services.
appropriate item was dispensed
- The Process Variation Among
As a result of these interventions, we were - The Medication Error
able to decrease the number of ENCs for - The Organization View of Change
several categories of medication errors. A
Management
linear regression analysis of these events
demonstrated the following reductions in - The Manual Data Collection
errors (Feb. 15, 2003–Feb. 7, 2004) Process
THANK
YOU !
Any questions?