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 MotorolaMotorola Their target was to reduce defect levels below 3.4 defects per (one) million opportunities (DPMO).defects per (one) million opportunities It is a registered trademark of Motorola and caused a saving of US$17 billion in 2006Motorola

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 SigmaPPM (Process (Defects per Million Capability) Opportunities) 2308,537 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