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.

医院用药错误代价高昂，并导致患者死亡率、发病率和医疗保健质量下降。错误是由糟糕的系统设计造成的，而不是由医护人员的表现造成的。因此，应将重点放在流程设计上。这项行动研究调查了精益六西格码在泰国公立医院减少住院药房配药错误的应用。通过多个精益六西格码工具的成功应用，精益六西格码的实施将 2018 年 3 月至 2019 年 11 月期间住院天数超过 14,000 天的每月分配错误从 29 次减少到 6 次，并提高了患者安全性。本研究中使用的精益六西格码工具是因果图、意大利面条图、五个为什么分析、项目章程、头脑风暴、控制图、和假设检验。本案例研究可以提高医院经理和医疗主任对精益六西格码的认识及其在预防和减少用药错误方面的好处。