Health Care Management Science

, Volume 11, Issue 1, pp 55–65 | Cite as

Understanding and reducing the medication delivery waste via systems mapping and analysis

  • Lukasz M. Mazur
  • Shi-Jie (Gary) Chen


The enormous gaps in the knowledge required to understand medication errors and their related costs (or wastes) in all hospital settings have become a growing national concern. Such gaps are often the major reasons causing risk for patient safety and creating waste to the hospital. However, medication delivery system cannot be successfully improved and implemented without a clear understanding of various process flows running around the entire hospital system. This paper presents a systems mapping and analysis method to help understand and reduce the medication delivery waste. The effectiveness of our method is illustrated by a case study that we conducted for the medication delivery process at Bozeman Deaconess Hospital, MT.


Healthcare systems Medication delivery errors Systems analysis Value stream mapping 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bates D, Cullen D, Laird N, L et al (1995) Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 274:29–34CrossRefGoogle Scholar
  2. 2.
    Leape L, Bates D, Cullen D et al (1995) Systems analysis of adverse drug events. JAMA 274:35–43CrossRefGoogle Scholar
  3. 3.
    Barker K, Flynn E, Pepper G et al (2002) Medication errors observed in 36 health care facilities. Arch Intern Med 162:1897–1903CrossRefGoogle Scholar
  4. 4.
    Institute of Medicine (2006) Preventing Medication Errors. Institute of Medicine Report, Washington, D.C.Google Scholar
  5. 5.
    Eskew J, Jacobi J, Buss W et al (2002) Using innovative technologies to set new safety standards for the infusion of intravenous medications. Hosp Pharm 37:1179–1189Google Scholar
  6. 6.
    Hatcher I, Sullivan M, Hutchinson J et al (2004) An intravenous medication safety system: preventing high-risk medication errors at the point of care. J Nurs Adm 34:437–439CrossRefGoogle Scholar
  7. 7.
    Williams C, Maddox R (2005) Implementation of an i.v. medication safety system. Am J Health–Syst Pharm 62:530–536Google Scholar
  8. 8.
    Wilson K, Sullivan M (2004) Preventing medication errors with smart infusion technology. Am J Health–Syst Pharm 61:177–183Google Scholar
  9. 9.
    Kaushal R, Bates D, Landrigan C et al (2001) Medication errors and adverse drug events in pediatric inpatients. JAMA 285:2114–2120CrossRefGoogle Scholar
  10. 10.
    Ross L, Wallace J, Paton J (2000) Medication errors in a pediatric teaching hospital in the UK: five years operational experience. Arch Dis Child 83:492–497CrossRefGoogle Scholar
  11. 11.
    Vanerveen T (2005) Averting highest-risk errors is first priority. Patient Safety and Quality Healthcare 2:16–21Google Scholar
  12. 12.
    Thurman S, Williams M, Gaffney F (2004) Intravenous medication safety systems help prevent harm and career-ending mistakes. Nurs Manage (Suppl.):2–4Google Scholar
  13. 13.
    Institute of Medicine (2001) Crossing the quality chasm: a new heath care system for the 21st century. Institute of Medicine Report, Washington, D.C.Google Scholar
  14. 14.
    Institute of Medicine (2005) Building a better delivery system: a new engineering/heath care partnership. Institute of Medicine Report, Washington, D.C.Google Scholar
  15. 15.
    Womack J, Jones D, Roos D (1990) The machine that changed the world: the story of lean production. Harper-Perennial, New YorkGoogle Scholar
  16. 16.
    Womack J, Jones D (1996) Lean Thinking. Simon & Schuster, New YorkGoogle Scholar
  17. 17.
    Liker J (1998) Becoming lean: inside stories of U.S. manufacturers. Productivity Press, Portland, ORGoogle Scholar
  18. 18.
    Monden Y (1993) Toyota Production System: An Integrated Approach to Just-In-Time. Second Edition, Industrial Engineering and Management Press, Norcross, GAGoogle Scholar
  19. 19.
    Rother M, Shook J (1998) Learning to see. The Lean Enterprise Institute, Inc., Brookline, MAGoogle Scholar
  20. 20.
    Thompson D, Wolf G, Spear S (2003) Driving improvement in patient care. J Nurs Adm 33:585–595CrossRefGoogle Scholar
  21. 21.
    Sobek D, Jimmerson C (2003) Applying the Toyota Production System to a hospital pharmacy. Industrial Engineering Research Conference, Portland, OregonGoogle Scholar
  22. 22.
    Sobek D, Jimmerson C (2004) A3 reports: tool for process improvement. Industrial Engineering Research Conference, Houston, TexasGoogle Scholar
  23. 23.
    Jimmerson C, Weber D, Sobek D (2005) Reducing waste and errors: piloting lean principles at IHC. Joint Comm J Qual Saf 83:249–257Google Scholar
  24. 24.
    Spear J (2005) Fixing healthcare from the inside, today. Harvard Business Review 78–91Google Scholar
  25. 25.
    Ghosh M, Sobek D (2007) Effective metaroutines for organizational problem solving, working paperGoogle Scholar
  26. 26.
    Tucker A, Edmondson A (2002) Managing routine exception: a model of nurse problem solving behavior. Adv Health Care Manag 3:87–113CrossRefGoogle Scholar
  27. 27.
    Tucker A, Edmondson C (2003) Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev 45:55–72Google Scholar
  28. 28.
    Classen D, Pestonik S, Evans S et al (1991) Computerized surveillance of adverse drug events in hospital patients. JAMA 266:2847–2851CrossRefGoogle Scholar
  29. 29.
    Evans R, Pestotnik S, Classen D (1998) A computer-assisted management program for antibiotics and other anti-infective agents. N Engl J Med 338:232–238CrossRefGoogle Scholar
  30. 30.
    Garibaldi R (1998) Computers and the quality of care: a clinician’s perspective. N Engl J Med 338:259–260CrossRefGoogle Scholar
  31. 31.
    Bates D, Teich J, Lee J et al (1999) The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 6:313–321Google Scholar
  32. 32.
    Casalino L, Gillies S, Schmittdiel J, Bodenheimer T et al (2003) External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases JAMA 289:434–441CrossRefGoogle Scholar
  33. 33.
    Breslow M (2005) The eICU solution: a technology-enabled care paradigm for ICU performance, in: Building Better Delivery System. Institute of Medicine Report, Washington, D.C.Google Scholar
  34. 34.
    Clayton P (2005) Obstacles to the implementation and acceptance of electronic medical record system, in: Building Better Delivery System. Institute of Medicine Report, Washington, D.C.Google Scholar
  35. 35.
    National Patient Safety Partnership (1999) Healthcare Leaders Urge Adoption of Methods to Reduce Adverse Drug Events. News ReleaseGoogle Scholar
  36. 36.
    National Coordinating Council for Medication Error Reporting and Prevention (2005) Defining a Problem and Developing Solutions. NCCMERPGoogle Scholar
  37. 37.
    Klein H, Isaacson J (2003) Making medication instructions usable. Ergon Des 11:7–11Google Scholar
  38. 38.
    Haberstroh C (1965) Organization, design and systems analysis in handbook of organizations. Rand McNally, ChicagoGoogle Scholar
  39. 39.
    Reason J (1990) Human error. Cambridge University Press, CambridgeGoogle Scholar
  40. 40.
    Reason J (1994) Forward in human error in medicine. Lawrence Erlbaum Associates, Marilyn Sue Bogner, Hillsdale, NJGoogle Scholar
  41. 41.
    American Society of Health-System Pharmacists (1996) Top-priority actions for preventing adverse drug events in hospitals, Recommendations of an expert panel. Am J Health–Syst Pharm 53:747–751Google Scholar
  42. 42.
    Flynn E, Barker K, Pepper G, Bates D et al (2002) Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health–Syst Pharm 59:436–446Google Scholar
  43. 43.
    Atkinson P, Hammersley M (1998) Ethnography and Participant Observation, in: Strategies of Qualitative Inquiry, ed. N. Denzin and S. Yvonna. Sage PublicationsGoogle Scholar
  44. 44.
    Cook R, Woods D, Miller C (1998) Tale of two stories: contrasting views of patient safety. National Patient Safety Foundation, ChicagoGoogle Scholar
  45. 45.
    Van Cott H (1994) Human errors: their causes and reductions in human error in medicine. Lawrence Erlbaum Associates, Marilyn Sue Bogner, Hillsdale, NJGoogle Scholar
  46. 46.
    Gandhi T, Seger D, Bates D (2000) Identifying drug safety issues: from research to practice. Int J Qual Health Care 12:69–76CrossRefGoogle Scholar
  47. 47.
    Adair G (1984) The Hawthorne effect: a reconsideration of the methodological artifact. J Appl Psychol 69:334–345CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  1. 1.Department of Mechanical and Industrial EngineeringMontana State UniversityBozemanUSA
  2. 2.Department of Industrial and Systems EngineeringNorthern Illinois UniversityDeKalbUSA

Personalised recommendations