Drug Topics - February 4, 2008 - (Page 3) www.drugtopics.com FEBRUARY 4, 2008 DRUG TOPICS 3 REDUCING YOUR RISK Ken Baker, pharmacist, JD Medication errors – A plan for quality uality is more than just reminding ourselves to be careful or deciding we are going to double check every time. Quality is more than a list of pharmacy best practices, such as using NDC checks and echoing back every telephoned prescription. Quality is a plan. In 1979 William Conway, an executive with the Nashua Corp., noted that Japanese manufacturers could produce copying machines at a higher level of quality and at lower costs than their American competitors. Conway sent a team of engineers to Japan to study this Japanese system of manufacturing and to learn the Japanese secrets. What Conway discovered was that the “Japanese system” was actually an American plan for quality. And he learned, by implementing this American plan, the Japanese had increased their efficiency. The increased efficiency led to increased profit margins. The increased margins led to the ability to decrease the selling price for the product. The overall result was higher quality and greater sales. Since this plan called for continuous quality improvement, it led to a continuous cycle of increased efficiency, increased margins, and lower prices. Conway found that this plan was introduced to Japanese manufacturers by an American mathematician brought to Japan by the American government following World War II. Conway hired this American mathematician, Edwards Deming, as a consultant to Nashua Corp. Many American companies began embracing Deming’s management and quality ideas, including Ford Motor Co., which hired Professor Deming as a consultant in 1981. Ford credited Deming as an important element in reversing Ford’s losses and introducing profitability that had exceeded General Motors for the first time since the 1920s. A study of Deming shows that quality does not happen consistently because we will it or because we try hard. The Deming philosophy of constantly increasing quality involves a plan. This plan works in pharmacy as well as in the manufacture of copying machines or automobiles. The first step toward quality is to identify the most common problems. In addition, we need to know where in the prescription-filling process mistakes are most likely to occur. Once we know where and what mistakes are most Q likely to occur, we can implement a plan to reduce these mistakes or to catch them before they reach the patient. To make the plan work, we must standardize the process. If the plan involves, for example, using the pharmacy best practice of performing an NDC check, it is done at a particular point in the process where we decide it would be most effective. Then we train every person who fills a prescription in our pharmacy to do it at the same step in the process. Not only does this standardize our process, it standardizes our training and increases efficiency. It also increases the likelihood that the selected best practice will be done for every prescription. A plan is only effective if everyone who uses the plan is trained in its use. Ford executives were surprised when Deming, who was hired to increase quality, spent most of his time talking to them about how to manage their operations. The role of management is to provide training and tools to those who do the actual work. Once a plan is in effect, we need to know whether it is working and then we begin thinking about how to further improve it. Deming was a mathematician. What he taught the Japanese, the Nashua Corp., Ford Motors, and hundreds of other companies was that in order to have a quality system, they needed to collect data. In order to know if the plan is working, we need to turn that data into statistics. In pharmacy this means we need to record every mistake that is made, whether it reaches a patient or was discovered and corrected before the prescription was delivered to the patient. From these data we can learn where, when, what, and how mistakes are made. At that point, we can adjust the workflow so that even fewer of these mistakes reach the patient. Statistics allow us to continuously increase quality. The plan for prescription quality begins with a commitment by management. It ends when every technician and every pharmacist serving patients attain perfection–in other words, quality improvement never ends. With a plan, however, every day the number of errors can be slightly lower than the day before and even lower the next day and the next and the next. Does your pharmacy have an organized plan for quality? consults in the areas of pharmacy error reduction and risk management. He is an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. For citations, contact Ken Baker at ken@kenbakerconsulting.com. THE AUTHOR http://www.drugtopics.com
Table of Contents Feed for the Digital Edition of Drug Topics - February 4, 2008 Drug Topics - February 4, 2008 Medication Errors: A Plan for Quality Can You Explain Pharmacy to an Eighth Grader? Latest News Roundup Drug Topics - February 4, 2008 Drug Topics - February 4, 2008 - Drug Topics - February 4, 2008 (Page 1) Drug Topics - February 4, 2008 - Drug Topics - February 4, 2008 (Page 2) Drug Topics - February 4, 2008 - Medication Errors: A Plan for Quality (Page 3) Drug Topics - February 4, 2008 - Can You Explain Pharmacy to an Eighth Grader? (Page 4) Drug Topics - February 4, 2008 - Latest News Roundup (Page 5) Drug Topics - February 4, 2008 - Latest News Roundup (Page 6)
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