Indenting error in medication management
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Indenting error in medication management
Indenting error in medication management
- 1. To reduce the wrong indent in Inpatient wards Project start date: Project End Date: Improvement Trend:
- 2. Project Team Details Member Name Project Sponsor: Dr. Rupali Basu, CEO Project Champion: Process Owner: Master Black Belt (Mentor): Dr Sujoy Kar Green Belt: Dr Mrinal Das Team Member(s): IP ward Pharmacist: Surojit Pal, Tanima Mukherjee, Mrinmoy Pal PAT: Shresthasri Ghosh Nursing Team: Sr Poulomi
- 3. Define Phase
- 4. Project Charter C I A M D Business Case: Apollo Gleneagles Hospitals, Kolkata Problem Statement: The current average incident of wrong indentation of medicines are 60 incidents approximately in last 5 months which can have a serious impact on patient safety. Project Goal/Objective: CTQ(s): To reduce the wrong indent in Inpatient wards Indenting process of medicines in wards CTQ Baseline Goal Operational Definition: Indent process of medicines in wards Current average number of incidents are 19 for last6 months To bring the number of incident towards zero. Indentation of medicines: The process includes the checking of the medicines from the patients files which is to be indented by the ward pharmacist, after which the data’s are entered in the med click. The details of the medicines are taken print out by the IP pharmacy followed by checking of the same by Prescription audit team. Bills are prepared and medicines are dispatched for the ward Project Business Benefit Project Scope To decrease the risk of medication error and patient safety Inpatient
- 5. Project Start Date Project End Date 01st Sept 2015 14th Feb 2016 Milestone: Define Measure Analyze Improve Control Projected Date: Actual Date:
- 6. Wrong dose form Wrong dosage / frequency / route / patient / time Therapeutic duplication Negatively interacting drugs Wrong spelling of the drugs Illegible drugs prescription Medication error – Look alike, spell alike, sound alike drugs
- 7. SIPOC To reduce the wrong indent in Inpatient wards Input Supplier Process Output Customer Input Supplier Process Output Customer Doctor Nursing Ward Pharmacist IP Pharmacist 1. Correct medicine 2. Correct Dosage 3. Patient treatment 1. Patient 1. Legibility 2. Out of formulary drug 3.Usage of abbreviations in prescriptions 4. Overload of work due to more number wards given to a particular staff 5. Less number of pharmacist Consultant prescribe the medicine Ward pharmacist indent the medicine through software Nurses inform the ward pharmacist Prescription audit by PAT team Bill preparation and medicine indent
- 8. As is process Map Ask doctor and confirm Illegible Legible (TRANSCRIBING) Ward pharmacist will indent the same in Medclick with proper dose, frequency and other details Checked by PAT No error found Forwarded to IP Pharmacy (DISPENSING) Medicines dispensed from pharmacy (Usual medication : within 45 mins, STAT medication: 15 mins) Informed to ward pharmacist Incident report raised Correct indent done Error found Medicine taken to the ward (ADMINISTERING) Medicine administered By the nurses (MONITERING) If any therapeutic alteration (PRESCRIBING) Medicine Prescribed in IP Medication chart
- 10. Indenting Error and their type of error Type of Error No of errors % Cumulative % Formulation 33 29.46 29.46 Route 32 28.57 58.04 Dose 22 19.64 77.68 Frequency 18 16.07 93.75 Other 3 2.68 96.43 Therapeutic 3 2.68 99.11 Medicine 1 0.89 100.00 112 100.00
- 11. Indenting Error Pareto Diagram Number of errors and their types 29.46 58.04 77.68 93.75 96.43 99.11 100.00 0 20 40 60 80 100 120 Types of error Number of error No of errors Cumulative %
- 12. Indenting Error ward wise Wards No of errors % Cumulative % 4th Left 19 17% 17 5th Left 17 15% 32 2nd Left 16 14% 46 1st Right 15 13% 59 4th Right 12 11% 70 3rd Right 8 7% 77 Onco 3rd 7 6% 83 2nd Right 6 5% 88 Onco 6th 4 4% 92 N & D 2 2% 94 3rd Left 2 2% 96 Onco 5th 2 2% 98 Onco 1st 1 1% 99 Onco 4th 1 1% 100 112
- 13. Indenting Error ward wise Pareto Diagram Number of error from various wards 17 32 46 59 70 77 83 88 92 94 96 98 99 100 0 5 10 15 20 Wards N o o f e rro rs 0 20 40 60 80 100 120 No of errors Cumulative %
- 14. Indenting Error time wise Pareto Diagram Time No of error % Cumulative % 8-12 noon 53 47.32 47.32 12-4 pm 36 32.14 79.46 4-8 pm 12 10.71 90.18 8-12 am 6 5.36 95.53 12-4 am 4 3.57 99.11 4-8 am 1 0.89 100.00 112
- 15. Indenting Error time wise Pareto Diagram Indenting Error time wise 29.5 58.1 77.7 93.8 96.5 97.4 98.2 99.1 100.0 0 5 10 15 20 25 30 35 Types of error N o o f erro r 0.0 20.0 40.0 60.0 80.0 100.0 120.0 No of error Cumulative %