In the wake of news about legal cases involving drug-dispensing mistakes in hospitals, a number of health systems are instituting a variety of actions to help prevent errors in dispensing “high-alert medications.” (See The Wall Street Journal, March 6, 2008.) These are medications that, when administered incorrectly, are likely to be harmful to a patient. To reduce the number of these incidences, hospitals are using a combination of process improvement and training. They are redesigning drug packaging, separating doses of drugs to prevent confusion, bar coding containers and providing personnel with equipment for checking bar codes before giving drugs to patients, creating systems of accountability among staff, using smart pumps that provide an alert if the dose is wrong, and retraining doctors, nurses, and other staff to use these new protocols.

Duke University Hospital is an example of an institution that has taken a comprehensive approach that combines “mistake-proofing” with computerized systems to help doctors and nurses monitor medications (See www.healthcarenews.com/story.cms?id=8793). Duke is using “Six Sigma” methods to control quality and reduce errors. Six Sigma, originally developed in manufacturing companies, is being adapted to health care and offers tools and a way of thinking that is effective for improving repeatable processes, such as drug dispensing.

This is all well and good, but not sufficient over the long term. These hospitals and health care systems should not assume that doctors, nurses, technicians, and other health care professionals will continue to use these tools and procedures consistently and effectively after one-time training. These institutions must commit to a culture that supports learning and change over time. Performance improvement needs continual monitoring, feedback, and reinforcement, which, after all, is the spirit of “Six Sigma”. The impact of these interventions on performance should be tracked and evaluated, this information should be brought to the attention of people involved in dispensing drugs, and the tools and procedures continually enhanced to reduce errors, with the ultimate goal of eliminating drug-dispensing mistakes in hospitals.

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