title: Using Six Sigma to improve once daily gentamicin dosing and therapeutic drug monitoring performance.
abstract: BACKGROUND
  Safe, effective therapy with the antimicrobial gentamicin requires good practice in dose selection and monitoring of serum levels. Suboptimal therapy occurs with breakdown in the process of drug dosing, serum blood sampling, laboratory processing and level interpretation. Unintentional underdosing may result. This improvement effort aimed to optimise this process in an academic teaching hospital using Six Sigma process improvement methodology.
  
  
  METHODS
  A multidisciplinary project team was formed. Process measures considered critical to quality were defined, and baseline practice was examined through process mapping and audit. Root cause analysis informed improvement measures. These included a new dosing and monitoring schedule, and standardised assay sampling and drug administration timing which maximised local capabilities. Three iterations of the improvement cycle were conducted over a 24-month period.
  
  
  RESULTS
  The attainment of serum level sampling in the required time window improved by 85% (p≤0.0001). A 66% improvement in accuracy of dosing was observed (p≤0.0001). Unnecessary dose omission while awaiting level results and inadvertent disruption to therapy due to dosing and monitoring process breakdown were eliminated. Average daily dose administered increased from 3.39 mg/kg to 4.78 mg/kg/day.
  
  
  CONCLUSIONS
  Using Six Sigma methodology enhanced gentamicin usage process performance. Local process related factors may adversely affect adherence to practice guidelines for gentamicin, a drug which is complex to use. It is vital to adapt dosing guidance and monitoring requirements so that they are capable of being implemented in the clinical environment as a matter of routine. Improvement may be achieved through a structured localised approach with multidisciplinary stakeholder involvement.
authors.affiliation: Pharmacy Department, Tallaght Hospital, Belgard Road, Tallaght, Dublin 24, Ireland. sean.egan@amnch.ie
authors.forename: Sean
authors.initials: S
authors.lastname: Egan
authors.forename: Philip G
authors.initials: PG
authors.lastname: Murphy
authors.forename: Jerome P
authors.initials: JP
authors.lastname: Fennell
authors.forename: Sinead
authors.initials: S
authors.lastname: Kelly
authors.forename: Mary
authors.initials: M
authors.lastname: Hickey
authors.forename: Carolyn
authors.initials: C
authors.lastname: McLean
authors.forename: Muriel
authors.initials: M
authors.lastname: Pate
authors.forename: Ciara
authors.initials: C
authors.lastname: Kirke
authors.forename: Annette
authors.initials: A
authors.lastname: Whiriskey
authors.forename: Niall
authors.initials: N
authors.lastname: Wall
authors.forename: Eddie
authors.initials: E
authors.lastname: McCullagh
authors.forename: Joan
authors.initials: J
authors.lastname: Murphy
authors.forename: Tim
authors.initials: T
authors.lastname: Delaney
mesh_terms: D054869:Clinical Audit; D004334:Drug Administration Schedule; D016903:Drug Monitoring / Q000592:standards*; D005839:Gentamicins / Q000008:administration & dosage* / Q000097:blood; D019983:Guideline Adherence; D006801:Humans; D055118:Medication Adherence; D010348:Patient Care Team; D017064:Process Assessment, Health Care; D011785:Quality Assurance, Health Care / Q000379:methods*; D017749:Total Quality Management
chemical_list: D005839:Gentamicins