Safe Drug dispensing using Six Sigma Methodology

1. Safe Drug dispensing using Six Sigma Methodology Dr Ho Chung Ping HKMA 20070705 Cpho@hkma.org

2. What is Six Sigma? • Total Quality management system originally developed by Motorola • Their target was to reduce defect levels below 3.4 defects per (one) million opportunities (DPMO). • It is a registered trademark of Motorola and caused a saving of US$17 billion in 2006

3. Sigma • The Greek letter s (sigma) refers to the standard deviation of a population. Sigma, or standard deviation, is used as a scaling factor to convert upper and lower specification limits to Z. Therefore, a process with three standard deviations between its mean and a spec limit would have a Z value of 3 and commonly would be referred to as a 3 sigma process.

4. Striving for Six Sigma Sigma PPM (Process (Defects per Million Capability) Opportunities) 2 308,537 3 66,807 4 6,210 5 233 6 3.4

5. Objective • The fundamental objective of the Six Sigma methodology is the implementation of a measurement-based strategy that focuses on process improvement and variation reduction through the application of Six Sigma improvement projects.

6. Six Sigma DMAIC • The Six Sigma DMAIC process (define, measure, analyze, improve, control) is an improvement system for existing processes falling below specification and looking for incremental improvement.

7. DMAIC in the Clinic • Define objective - reduce dispensing error to 3 sigma • Measure – report and record dispensing error • Analysis – elucidate possible source of error in the clinic • Improve - charter • Control – staff training

8. Analysis: Possible source of error in dispensing • Each clinic should do its own analysis, but all falls into two categories • Errors in drug procurement • Errors in preparation • Errors in drug dispensing

9. Analysis: Errors in Drug procurement • Error in drug ordering over the phone • Failure to check the medicine on arrival • Put in wrong location

10. Analysis: Problem in drug dispensing • Failure to get the correct medicine • Changing brand names • Similar medicine names • Similar tablet appearance

11. Analysis: Error in labeling • Instruction not clear • Before meals/after meals • Warning notices not complete • ACEI – contraindicated in pregnancy • Allopurinol and sulphonamide –skin reactions • No labels after batch preparation • Drug action not complete

12. Analysis: Others errors • Error in quantity • Improved with computer software • Error in preparation • Error during transfer of medicine • Error in drug compounding and dilution • Error in quality of medicine • Expired medicine

13. Improve: drug procurement • Drug ordering by phone and by fax. • Forms will be generated by computer using the database from the clinic management system • Clinic nurse will retain the form • Drugs arrival checked & signed by 2 staff members • Doctors to verify occasionally

15. Improve: drug dispensing • Use generic names as far as possible • Use furosemide (fursemide) instead of lasix • Use metalozone instead of diulo • Use domperidone instead of motilium • Eliminate drugs with similar drug names • Beware of drugs with similar appearance

18. Improve – drug dispensing procedure • Staff training • State the drug attributes to be checked • Drugs should be cross-checked after dispensing • Checked by the doctor before issue to patients

19. Staff training • Attending courses • In house training • The number of medications used in individual clinic is limited • Staff will have more thorough understanding of the drug used in her clinic • Doctor can give more precise information

21. Control: Mistake Proofing • Mistake-proofing devices prevent defects by preventing errors or by predicting when errors could occur. • In the Improve phase, mistake proofing is used to design your process so it will be impossible to make mistakes

22. Control – documentation and supervision • Set up a dispensing charter/ or use HKMA drug dispensing manual • Supervision by more senior staff

24. Charter • A charter is a document that establishes a purpose and plan for the project. It contains a statement of the problem, the scope of the project (including the process to be improved), an improvement goal, a plan and schedule for the project, estimated financial benefits, and a list of team members and their roles.

25. Six sigma in clinic dispensing • The Six Sigma principle can be applied in dispensing in small private clinics • Collection of data not easy in clinics (?culture) • Pooled data useful in the long term • Good system and staff training the cornerstone of safe practice