Abstract
Medical errors ranked first out of 10 major reported incidents (24.8%). Lean and Safety project (L&S project), defined as a combination of Health Lean Management and Clinical Risk Management. This study aimed at identifying the main problem related to medication error and at proposing improvement through L&S project. We implemented the five steps of the L&S project in the Pharmacy unit. The five steps were a determination of triggers, organizational aspects, phases, outcomes, enablers, and obstacles. The main problem was the drug administration error (rate 6%). The L&S project approach resulted in a seven safety procedure, which was a safe prescription, safe patient category, safe seven correct, safe etiquette, safe dispensing, safe distribution, and safety information. Identification of the main problem in medication error is a drug administration error. The proposed improvement is carried out through L&S project with seven safety procedures.
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