Health Care Management Science

, Volume 12, Issue 1, pp 56–66 | Cite as

An empirical study for medication delivery improvement based on healthcare professionals’ perceptions of medication delivery system

  • Lukasz M. Mazur
  • Shi-Jie (Gary) ChenEmail author


Medication errors are major safety concerns in all hospital settings. The insufficient knowledge about managerial and process improvement strategies required to reduce medication errors can be considered as one of the most important factors holding back hospitals from achieving the desired goals for patient safety. However, strategies for medication error reduction cannot be successfully implemented without a clear understanding of factors affecting medication delivery errors. This paper presents a study in which healthcare professionals’ perceptions on three factors, namely (1) technical complexity of tasks/connections; (2) resources problems; and (3) qualification of human resources, are analyzed within the medication delivery system at one community hospital. The outcomes of this research are a theoretical model for reducing medication delivery errors and a set of workflow design rules for healthcare professionals to continuously reduce medication delivery errors.


Healthcare systems Management strategies Medication delivery errors Toyota Production System (TPS) 


  1. 1.
    Institute of Medicine Preventing Medication Errors. Institute of Medicine Report, Washington, D.C., 2006Google Scholar
  2. 2.
    Weingart S, Page D (2004) Implications for practice: challenges for healthcare leaders in fostering patient safety. Qual Saf Health Care 13:ii52–ii56CrossRefGoogle Scholar
  3. 3.
    Ramanujam R, Rousseau D (2006) The challenges are organizational, not just clinical. J Organ Behav 27:811–827 doi: 10.1002/job.411 CrossRefGoogle Scholar
  4. 4.
    Perrow C (1984) Normal accidents: Living with high-risk technologies. Princeton University Press, PrincetonGoogle Scholar
  5. 5.
    Tucker A, Edmondson A (2002) Managing routine exception: a model of nurse problem solving behavior. Adv Healthc Manage 3:87–113CrossRefGoogle Scholar
  6. 6.
    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
  7. 7.
    Tucker A (2004) The impact of operational failures on hospital nurses and their patients. J Oper Manage 22:151–169 doi: 10.1016/j.jom.2003.12.006 CrossRefGoogle Scholar
  8. 8.
    Thompson D, Wolf G, Spear S (2003) Driving improvement in patient care. J Nurs Adm 33:585–595 doi: 10.1097/00005110-200311000-00008 CrossRefGoogle Scholar
  9. 9.
    Patel V, Branch T, Arocha J (2002) Errors in interpreting quantities as procedures: the case of pharmaceutical label. Int J Med Inform 65:193–211 doi: 10.1016/S1386-5056(02)00045-X CrossRefGoogle Scholar
  10. 10.
    Uhlig P (2001) Improving patient care in hospital. J Innovative Manage 7:23–45Google Scholar
  11. 11.
    Spear S, Bowen H (1999) Decoding the DNA of the Toyota Production System. Harv Bus Rev 77:97–106Google Scholar
  12. 12.
    Shingo S (1989) A study of the toyota production system from an industrial engineering viewpoint. Productivity, PortlandGoogle Scholar
  13. 13.
    Womack JP, Jones DT (1996) Lean Thinking. Simon and Schuster, New YorkGoogle Scholar
  14. 14.
    Sobek D, Jimmerson C (2003) Applying the Toyota Production System to a hospital pharmacy. Paper presented at the Industrial Engineering Research Conference, Portland, OregonGoogle Scholar
  15. 15.
    Sobek D, Jimmerson C (2004) A3 reports: Tool for process improvement. Paper presented in the Industrial Engineering Research Conference, Houston, TexasGoogle Scholar
  16. 16.
    Jimmerson C, Weber D, Sobek D (2005) Reducing waste and errors: piloting lean principles at IHC. Jt Comm J Qual Saf 31:249–257Google Scholar
  17. 17.
    Spear S (2005) Fixing healthcare from the inside, today. Harv Bus Rev 83:78–91Google Scholar
  18. 18.
    Mazur L, Chen S (2007) Improving medication delivery using systems engineering approach. Proceedings of Industrial Engineering Research Conference, NashvilleGoogle Scholar
  19. 19.
    Mazur L, Chen S (2008) Understanding and reducing waste due to medication errors via systems mapping and analysis. Health Care Manage Sci 11:55–65 doi: 10.1007/s10729-007-9024-9 CrossRefGoogle Scholar
  20. 20.
    DeWalt K, DeWalt B (2002) Participant observation. AltaMira, Walnut CreekGoogle Scholar
  21. 21.
    Strauss A, Corbin J (1998) Basics of qualitative research: techniques and procedures for developing grounded theory. Sage, Newbury ParkGoogle Scholar
  22. 22.
    Uribe CL, Schweikhart SB, Pathak DS, Dow M, Marsh GB (2002) Perceived barriers to medication error reporting: an explanatory investigation. J Healthc Manag 47:263–280Google Scholar
  23. 23.
    Joint Commission (2007) National Patient Safety Goals. Retrieved on May 28, 2007Google Scholar
  24. 24.
    Slavitt D, Stamps P, Piedmont E, Haase A (1978) Nurses’ satisfaction with their work situation. Nurs Res 27:114–120 doi: 10.1097/00006199-197803000-00018 CrossRefGoogle Scholar
  25. 25.
    Aiken L, Patrician P (2000) Measuring organizational traits of hospitals: the revised nursing work index. Nurs Res 49:146–153 doi: 10.1097/00006199-200005000-00006 CrossRefGoogle Scholar
  26. 26.
    Havens D, Aiken L (1999) Shaping systems to promote desired outcomes. J Nurs Adm 29:14–20 doi: 10.1097/00005110-199902000-00006 Google Scholar
  27. 27.
    Hackman J (1987) The design of work teams. In: Lorsch J (ed) Handbook of organizational behavior. Prentice-Hall, Englewood CliffsGoogle Scholar
  28. 28.
    Roberts K (1990) Some characteristics of high reliability organizations. Organ Sci 1:160–177CrossRefGoogle Scholar
  29. 29.
    Roberts K, Bea R (2001) Must accidents happen? Lessons from high reliability organizations. Acad Manag Exec 15:70–79Google Scholar
  30. 30.
    Reason J (2004) Beyond the organizational accident: the need for ‘error wisdom’ on the frontline. Qual Saf Health Care 13:28–33 doi: 10.1136/qshc.2003.009548 CrossRefGoogle Scholar
  31. 31.
    Tucker A, Spear S (2006) Operational failures and interruptions in hospital nursing. Health Serv Res 41:643–662 doi: 10.1111/j.1475-6773.2006.00502.x CrossRefGoogle Scholar
  32. 32.
    Anderson J, Ramanujam R, Hensel D, Anderson M, Sirio C (2006) The need for organizational change in patient safety. Int J Med Inform 75:809–817 doi: 10.1016/j.ijmedinf.2006.05.043 CrossRefGoogle Scholar
  33. 33.
    Haberstroh C (1965) Organization, Design and Systems Analysis in Handbook of Organizations. Rand McNally, ChicagoGoogle Scholar
  34. 34.
    Burke T, McKee J, Wilson H, Donahue R, Batenhorst A, Pathak D (2000) A comparison of time-and-motion and self-reporting methods of work measurement. J Nurs Adm 30:118–125 doi: 10.1097/00005110-200003000-00003 CrossRefGoogle Scholar
  35. 35.
    Miles M, Huberman A (1994) Qualitative data analysis: an expanded sourcebook. Sage, Thousand OaksGoogle Scholar
  36. 36.
    Redelmeier DA (2005) Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med 142:115–120Google Scholar
  37. 37.
    Croskerry P (2003) Cognitive forcing strategies in clinical decision-making. Ann Emerg Med 41:110–120 doi: 10.1067/mem.2003.22 CrossRefGoogle Scholar
  38. 38.
    Croskerry P (2003) The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 78:775–780 doi: 10.1097/00001888-200308000-00003 CrossRefGoogle Scholar
  39. 39.
    Gilovich T, Medvec VH, Savitsky K (2000) The spotlight effect in social judgment: an egocentric bias in estimates of the salience of one’s own actions and appearance. J Pers Soc Psychol 78:211–222 doi: 10.1037/0022-3514.78.2.211 CrossRefGoogle Scholar
  40. 40.
    Jones E, Nisbett R (1985) Sex of employee and sex of supervisor: effect on attributions for the causality of success and failure. Sex Roles J Res 12:257–269 doi: 10.1007/BF00287592 CrossRefGoogle Scholar
  41. 41.
    Weary G, Edwards J (1994) Individual differences in causal uncertainty. J Pers Soc Psychol 67:308–318 doi: 10.1037/0022-3514.67.2.308 CrossRefGoogle Scholar
  42. 42.
    Science Applications International Corporation: Probabilistic risk assessment of the space shuttle. NASA/HQ, 28 February, 1995Google Scholar
  43. 43.
    Fragola J (1996) Space shuttle probabilistic risk assessment. Proceedings Annual Reliability and Maintainability SymposiumGoogle Scholar
  44. 44.
    Marx DA, Slonim AD (2003) Assessing patient safety risk before the injury occurs: an introduction to sociotechnical probabilistic risk modeling in health care. Qual Saf Health Care 12:33–38 doi: 10.1136/qhc.12.suppl_2.ii33 CrossRefGoogle Scholar
  45. 45.
    Kanki BG, Marx D, Hale MJ (2004) Socio-technical probabilistic risk assessment: its capabilities and limitations. Proceedings of International Conference on Probabilistic Safety Assessment and Management. Berlin, GermanyGoogle Scholar
  46. 46.
    Hovor C, O’Donnell LT (2007) Probabilistic risk analysis of medication error. Qual Manag Health Care 16:349–253CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Industrial Extension ServiceNorth Carolina State UniversityRaleighUSA
  2. 2.Department of Industrial and Systems EngineeringNorthern Illinois UniversityDeKalbUSA

Personalised recommendations