Reducing pharmacy medication errors using Lean Six Sigma: A Thai hospital case study

Hospital medication errors are costly and contribute to patient mortality, morbidity, and decreased health care quality. Errors result from poor systems design more commonly than from healthcare staff performance. As such, a focus should be directed to process design. This action research study examines the application of Lean Six Sigma to reduce inpatient pharmacy dispensing errors in a Thai public hospital. Through the successful application of multiple Lean Six Sigma tools, the implementation of Lean Six Sigma reduced monthly dispensing errors from 29 incidents to 6 incidents over 14,000 total inpatient days between March 2018 and November 2019, and improved patient safety. Lean Six Sigma tools used in this study were cause-and-effect diagrams, spaghetti diagrams, five-why analysis, project charters, brainstorming, control charts, and hypothesis testing. This case study can improve hospital manager and medical director awareness of Lean Six Sigma and its benefits relative to the prevention and reduction of medication errors.