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Health Care Acad J. 2014; 1(1): 67-73

Using Quality Improvement Tools in Risk Management: Medication Error Example

Şeyda Seren İntepeler, Menevşe Samur, Hasan Fehmi Dirik.

Aim: This study has been conducted for the purpose of discussing the impact of quality improvement tools that have an important place in medical services on patient safety over the example of medication error.
Method: Through scanning the literature related with the topic, it has been realised that medication error is the most serious dimension of the medical errors, so this study has been conducted on one of the examples of an experienced medication error (applying a wrong chemotherapeutic agent to the patient). Risky situations that threaten the patient safety have been determined over the example and their hypothetical effects have been analyzed through the quality improvement tools such as Root Cause Analysis (RCA), Plan-Do-Check-Act (PDCA), Health Failure Mode and Effects Analysis (HFMEA), Six Sigma and Lean.
Findıngs: It is found through RCA that the main reasons of the error are related with the factors such as organizational, qualitative and infrastructural. It is planned with the help of PDCA cycle to hang medicine charts for medicines with high risks that are similar in writing/pronouncing and to hang chemotherapy protocols, and to enable unit orientation and certification education opportunities. Besides, it is suggested to switch to computerized physician order system for it is thought to be effective in decreasing the errors such as illegible hand writing, prescribing the dose/time/route of the medicine wrong and transcribing the physician order down the nurse observation form wrong. With HFMEA, potential error types and classification of the errors based on their levels are foreseen and it is planned to create a process flow chart. After the implementation of the system, with a cooperation within the team members, the errors which occur during the computerized physician order entry must be determined and corrected by the methodologies Six Sigma and Lean.
Result: While the causes for error are analyzed with the reactive methods, preventing the errors before they occur can be done with proactive methods. Within this study, it can be suggested to use these methods frequently in all healthcare institutions and to conduct studies that show their effect in academic fields. By using quality tools in healthcare systems the patient safety will be affected positively and errors, cost, the loss of time and the length of staying in hospital will decrease.

Key words: Quality improvement tools, risk menagement, medication error, patient safety

Article Language: Turkish English

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