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64. To determine where the longest time delays were occurring, the team randomly chose 50 orders from those received
during a one-week period. As members tracked these selected orders through the distribution center, they noted the time
each entered and left the various activity areas appearing on the order processing flowchart.
65. During a brainstorming session, a part picker suggested the three humps of the histogram reflected the number of trips
made to the parts storage area of the distribution center to complete an order. He explained that many orders were filled
with just one trip, but two were sometimes required and, on occasion, even three. Thus, the left hump could consist of
times an order was completed with only one trip, the middle could represent those requiring two, whereas the third could
be those in which three trips were needed.
66. After a number of brainstorming sessions, the team set up by the distribution center to reduce order processing time
eventually decided that the push carts used by the part pickers to carry the parts were too small. When part pickers were
gathering parts to fill a large order, the cart became full long before all the needed parts were gathered. The picker had to
travel to the inspection area to empty the cart and make a return trip to the warehouse to retrieve the remainder of the
order.
67. The steps with the highest degree of variability and the greatest chance for error in the analysis of medication delivery
by IV infusions were as follows:
1. MD ordering practices (i.e., lack of standardization in medication description, dosage, concentration, etc.)
2. IV drip preparation (lack of standardization by pharmacy and nursing of IV bag concentrations)
3. RN labeling and documentation of IV concentrations
68. The consortium is currently addressing three major efforts: (1) improved identification and reporting of health care
errors, (2) deployment of the Six Sigma methodology to reduce errors, and (3) testing and implementation of technical
solutions to improve patient safety.