Abstract
Preventable medication-related adverse events continue to occur in the healthcare setting. While the Institute of Medicine’s To Err is Human, published in 2000, highlighted the prevalence of medical and medication-related errors in patient morbidity and mortality, there has not been significant documented progress in addressing system contributors to medication errors. The lack of progress may be related to the myriad of pharmaceutical options now available and the nuances of optimizing drug therapy to achieve desired outcomes and prevent undesirable outcomes. However, on a broader scale, there may be opportunities to focus on the design and performance of the many processes that are part of the medication system. Errors may occur in the storage, prescribing, transcription, preparation and dispensing, or administration and monitoring of medications. Each of these nodes of the medication system, with its many components, is prone to failure, resulting in harm to patients. The pharmacist is uniquely trained to be able to impact medication safety at the individual patient level through medication management skills that are part of the clinical pharmacist’s role, but also to analyze the performance of medication processes and to lead redesign efforts to mitigate drug-related outcomes that may cause harm. One population that can benefit from a focus on medication safety through clinical pharmacy services and medication safety programs is the elderly, who are at risk for adverse drug events due to their many co-morbidities and the number of medications often used. This article describes the medication safety systems and provides a blueprint for creating a foundation for medication safety programs within healthcare organizations. The specific role of pharmacists and clinical pharmacy services in medication safety is also discussed here and in other articles in this Theme Issue.
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Glossary: Performance Improvement Terms
Glossary: Performance Improvement Terms
Lean Six Sigma This is the integration of two performance-improvement philosophies: ‘Lean’ incorporates methods and tools that address removing the waste within a process for better performance; ‘Six Sigma’ focuses on reduction of errors to an extremely low level through different tools and methods. Combined, Lean Six Sigma can be a powerful collection of tools and methods to improve the performance of most processes.
DMAIC process A format for process improvement that is part of Six Sigma, in which improvement initiatives are conducted in phases with careful analysis. The phases are Define, Measure, Analyze, Improve, and Control, and they reference the scoping of the project, the clarification of the focus, identifying measures for the process, analyzing the process and why failures occur, developing the solutions, and sustaining the outcome.
PDCA: Plan Do, Check, Act This is a four-step process for continuous performance improvement, where changes leading to improvement are planned, changes are tested in a pilot process, measures confirm that the change has resulted in improvement, and then full implementation of the change occurs.
Change Acceleration Process a performance-improvement method to seek stakeholder buy-in for change, which is considered a critical element to effective performance improvement, in addition to creating an effective change to the process. This method was developed by General Electric.
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Mansur, J.M. Medication Safety Systems and the Important Role of Pharmacists. Drugs Aging 33, 213–221 (2016). https://doi.org/10.1007/s40266-016-0358-1
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DOI: https://doi.org/10.1007/s40266-016-0358-1