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Medication management is a complex process, at high risk of error with life threatening consequences. The focus should be on devising strategies to avoid errors and make the process self-reliable by ensuring prevention of errors and/or error detection at subsequent stages. The purpose of this paper is to use failure mode effect analysis (FMEA), a systematic proactive tool, to identify the likelihood and the causes for the process to fail at various steps and prioritise them to devise risk reduction strategies to improve patient safety.

The study was designed as an observational analytical study of medication management process in the inpatient area of a multi-speciality hospital in Gurgaon, Haryana, India. A team was made to study the complex process of medication management in the hospital. FMEA tool was used. Corrective actions were developed based on the prioritised failure modes which were implemented and monitored.

The percentage distribution of medication errors as per the observation made by the team was found to be maximum of transcription errors (37 per cent) followed by administration errors (29 per cent) indicating the need to identify the causes and effects of their occurrence. In all, 11 failure modes were identified out of which major five were prioritised based on the risk priority number (RPN). The process was repeated after corrective actions were taken which resulted in about 40 per cent (average) and around 60 per cent reduction in the RPN of prioritised failure modes.

FMEA is a time consuming process and requires a multidisciplinary team which has good understanding of the process being analysed. FMEA only helps in identifying the possibilities of a process to fail, it does not eliminate them, additional efforts are required to develop action plans and implement them. Frank discussion and agreement among the team members is required not only for successfully conducing FMEA but also for implementing the corrective actions.

FMEA is an effective proactive risk-assessment tool and is a continuous process which can be continued in phases. The corrective actions taken resulted in reduction in RPN, subjected to further evaluation and usage by others depending on the facility type.

The application of the tool helped the hospital in identifying failures in medication management process, thereby prioritising and correcting them leading to improvement.

The purpose of this paper is to analyse the adoption of a multimodal medication management system (MMS) targeted on older people and home care professionals. The paper aims to describe the expectations of the system and the user experience findings from an empirical qualitative field trial. The field trial results are used to discuss how MMSs should be designed in order to improve adherence to medications.

The paper suggests that building a multimodal medicine management system targeted on both older users and home care professionals brings many benefits over electronic medicine dispenser systems or general reminder systems. The research process uses an iterative prototyping approach including phases of requirements analysis and concept design, prototype building and evaluation in a field trial.

The study demonstrates how a system that merely satisfied users during the prototype building phase does not necessarily succeed as well as expected in the field trials. It would be important to consider reasons for medication non-adherence and non-technology factors influencing willingness to adopt new assistive devices in order to promote diffusion of new MMSs at home. The paper also discusses how the different persuasive functionalities of the system addressed patient-centred factors influencing non-adherence and how they could be addressed.

This study has some limitations. The actual adherence to medications was not measured. However, in the future, it will be important to study how the MMSs influence medication adherence. Also, the user experiences of the home care professionals were not studied in the field trials. Home care professionals who were involved in the user studies and trials merely estimated the value for their patients and not for themselves.

This paper analyses design issues relevant when designing systems to help older people manage their medications.

The purpose of this paper is to examine power relations embedded in verbal and non-verbal medication communication processes that involve nurses, doctors, pharmacists and patients in two general medical wards of an acute care hospital.

This paper reports on the findings of an ethnographic study investigating medication communication processes in hospital spatial environments. It was theoretically informed by the work of Norman Fairclough. Data collection methods comprising video-recordings and video reflexive focus groups were employed. Fairclough's critical discourse analytic framework guided data analysis.

Four different forms of power relations between clinician-patient, nurse-doctor, clinician-organisation and multidisciplinary interactions were uncovered. Nurses asserted their professional autonomy when communicating with doctors about medications by offering specific advice on medical prescribing and challenging medication decisions. Video reflexivity enabled nurses to critically examine their contribution to medication decision-making processes. Clinicians of different disciplines openly contested the organisational structure of patient allocation during medical discussions about management options. Clinicians of different disciplines also engaged in medication communication interchangeably to accomplish patient discharge.

An investigation of existing power relations embedded in medication communication processes within specific clinical contexts can lead to a better understanding of medication safety practices. Video reflexive focus groups are helpful in encouraging clinicians to reflect on their practice and consider ways in which it could be improved in how power relations are played out.

A growing ageing population with complex healthcare needs is a challenge to the organisation of healthcare support for older people residing in care homes. The lack of specialised healthcare support for care home residents has resulted in poorer outcomes, compared with community-dwelling older people. However, little is known about the forms, staff mix, organisation and delivery of such services for residents’ physical healthcare needs. The paper aims to discuss these issues.

This systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aimed to provide an overview of the range of healthcare services delivered to care homes and to identify core features of variation in their organisation, activities and responsibilities. The eligibility criteria for studies were services designed to address the physical healthcare needs of older people, permanently residing in care homes, with or without nursing. To search the literature, terms relating to care homes, healthcare and older people, across ten electronic databases were used. The quality of service descriptions was appraised using a rating tool designed for the study. The evidence was synthesised, by means of a narrative summary, according to key areas of variation, into models of healthcare support with examples of their relative effectiveness.

In total, 84 studies, covering 74 interventions, identified a diverse range of specialist healthcare support services, suggesting a wide variety of ways of delivering healthcare support to care homes. These fell within five models: assessment – no consultant; assessment with consultant; assessment/management – no consultant; assessment/management with consultant; and training and support. The predominant model offered a combination of assessment and management. Overall, there was a lack of detail in the data, making judgements of relative effectiveness difficult. Recommendations for future research include the need for clearer descriptions of interventions and particularly of data on resident-level costs and effectiveness, as well as better explanations of how services are implemented (review registration: PROSPERO CRD42017081161).

There is considerable debate about the best means of providing healthcare to older people in care homes. A number of specialist initiatives have developed and this review seeks to bring these together in a comparative approach deriving models of care of value to policy makers and commissioners.

The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU).

Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation.

In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility.

The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

Learning outcomes are as follows: students will discover the importance of process orientation in management; students will determine the root cause of the problem by applying root cause analysis technique; students will identify the failure modes, analyze their effect, score them on a scale and prioritize the corrective action to prevent the failures; students will analyze the processes and propose error-proof system/s; and students will analyze organizational culture and ethical issues.

Purpose: This case study is intended as a class-exercise, for students to discover the importance of process-orientation in management, analyze the ethical dilemma in health care and to apply quality management techniques, such as five-why, root cause analysis, failure mode and effect analysis (FMEA) and error-proofing, in the management of the health-care and service industry. Design/methodology/approach: A voluntary reporting of a case of “radiation overdose” in a hospital’s radio therapy treatment unit, which led to an ethical dilemma. Consequently, a study was conducted to establish the causes of the incident and to develop a fail-proof system, to avoid recurrence. Findings: After careful analysis of the process-flow and the root causes, 25 potential failure modes were detected and the team had assigned a risk priority number (RPN) for each potential incident, selected the top ten RPNs and developed an error-proofing system to prevent recurrence. Subsequently, the improvement process was carried out for all the 25 potential incidents and a new control mechanism was implemented. The question of ethical dilemma remained unresolved. Research limitations/implications: Ishikawa diagram, FMEA and Poka-Yoke techniques require a multi-disciplinary team with process knowledge in identifying the possible root causes for errors, potential risks and also the possible error-proofing method/s. Besides, these techniques need frank discussions and agreement among team members on the efforts for the development of action plan, implementation and control of the new processes. Practical implications: Students can take the case data to identify root cause analysis and the RPN (RPN = possibility of detection × probability of occurrence × severity), to redesign the protocols, through systematic identification of the deficiencies of the existing protocols. Further, they can recommend quality improvement projects. Faculty can navigate the case session orientation, emphasizing quality management or ethical practices, depending on the course for which the case is selected.

MBA or PG Diploma in Management – health-care management, hospital administration, operations management, services operations, total quality management (TQM) and ethics.

Teaching Notes are available for educators only.

CSS 9: Operations and Logistics.

Pharmacy services start right from prescribing medicines and continue as the medication’s effect is monitored. Hospital and community pharmacy staff promote rational prescribing and medicine use. Consequentially, pharmacy is a complex and busy field. Often there are peak workload hours when patients must wait, which is associated with patient dissatisfaction that may negatively affect patient experience and the organisation’s reputation. The purpose of this paper is to enlist techniques, methods and technological advancements that have been successfully employed to reduce patient waiting time.

A database search was conducted in 2017 to locate articles addressing methods and technologies that reduce pharmacy waiting time. The literature revealed various techniques and technologies like queuing theory, tele-pharmacy, evidence-based pharmacy design, automated pharmacy systems (robotics), system modelling and simulation and the Six Sigma method for identifying potential problems associated with increased wait time.

The authors conclude that various techniques and methods, including automated queuing technology, tele-pharmacy, automated pharmacy devices/machines for quick and accurate filling and dispensing, computer simulation modelling, evidence-based pharmacy infrastructure for smooth workflow and Six Sigma can maintain customer satisfaction, reduce waiting time, attract new customers, decrease workload and improve the organisation’s reputation.

The authors conclude that various techniques and methods, including automated queuing technology, tele-pharmacy, automated pharmacy devices/machines for quick and accurate filling and dispensing, computer simulation modelling, evidence-based pharmacy infrastructure for smooth workflow and Six Sigma methodology can maintain customer satisfaction, reduce waiting time, attract new customers, decrease workload and improve the organisation’s reputation.

The authors carried out a literature search and identified the techniques that have been successfully implemented to reduce pharmacy patient waiting time and methods that can identify potential process behind medication dispensation delays.

Due to recent Affordable Care Act reforms, prevention of readmissions is a salient issue for hospitals that participate in Medicare, as they are now held accountable for patients who receive post-acute care in facilities over which hospitals have little influence to monitor care. Using resource dependence and transaction cost economics to describe the theoretical advantages of hospital ownership of post-acute care facilities (PACs), we empirically test whether hospitals that own PACs experience reduced readmissions. Our findings indicate partial support for the predicted relationship between PAC ownership and readmission rates. We found that hospital ownership of a skilled-nursing facility (SNF) was related to a lower readmissions rate for some patients, while ownership of other types of PACs did not result in significant findings. Our results offer support for the theoretical advantages of ownership, however, the savings realized by ownership may not merit the ownership investment.

Failure modes and effects analysis (FMEA) is a practical tool to evaluate risks, discover failures in a proactive manner and propose corrective actions to reduce or eliminate potential risks. The purpose of this paper is to apply FMEA technique to examine the hazards associated with the process of service delivery in intensive care unit (ICU) of a tertiary hospital in Yazd, Iran.

This was a before-after study conducted between March 2013 and December 2014. By forming a FMEA team, all potential hazards associated with ICU services – their frequency and severity – were identified. Then risk priority number was calculated for each activity as an indicator representing high priority areas that need special attention and resource allocation.

Eight failure modes with highest priority scores including endotracheal tube defect, wrong placement of endotracheal tube, EVD interface, aspiration failure during suctioning, chest tube failure, tissue injury and deep vein thrombosis were selected for improvement. Findings affirmed that improvement strategies were generally satisfying and significantly decreased total failures.

Application of FMEA in ICUs proved to be effective in proactively decreasing the risk of failures and corrected the control measures up to acceptable levels in all eight areas of function.

Using a prospective risk assessment approach, such as FMEA, could be beneficial in dealing with potential failures through proposing preventive actions in a proactive manner. The method could be used as a tool for healthcare continuous quality improvement so that the method identifies both systemic and human errors, and offers practical advice to deal effectively with them.

The Balanced Scorecard (BSC) emphasizes on the of information system to track a limited number of balanced metrics (measures and indicators) that are closely aligned with organization's goals. This study investigates how system integration in different forms is related to the success of using the BSC for performance measurement. The use of a BSC in performance evaluation is considered in five contexts: determining cost, measuring efficiency, ensuring quality and customer satisfaction measure, promoting continuous innovation and monitoring contract negotiation. The findings indicate that system integration defined in the study positively relates to the success of using the BSC in all five decision perspectives. The findings conclude that hospitals need a streamlined, information integration across the continuum of care to better assess the operation results, in both organizational and technical perspectives.