Proceedings of the 2018 IISE Annual Conference K. Barker, D. Berry, C. Rainwater, eds. The Effect of Poka-Yoke Implementation On Intravenous Medication Error In Hospital Inpatient Pharmacy Sasan Torabzadeh Khorasani and Ramyar Feizi Texas Tech University Lubbock, Texas Hamid Tohidi South Tehran Azad University Tehran, Iran Abstract Pharmaceutical products are one of the critical elements of the healthcare industry because of the significant role they play in the rising costs of this sector. One of the principal contributors to such costs is intravenous medication error in hospital inpatient pharmacies. With regards to intravenous drugs, error is mainly related to preparation and administration. Lean thinking has been utilized in healthcare for the elimination of error and waste. One reason for significant drug error in hospitals is staff errors while working. Poka-yoke is a lean methodology which prevents staff members from making errors by creating a visual or signal to show a characteristic state. In this work, the effect of poka-yoke on errors related to intravenous medications in a case study is examined. Then, after detecting them, recommendations are made to prevent those which can lead to cost and trauma. Keywords Error, Intravenous Medication Error, Human Error Prevention, Hospital Inpatient Pharmacy, Poka-Yoke, Cost 1. Introduction It’s part of human nature to make mistakes, but it is also part of their nature to come up with solutions to prevent these errors. It’s obvious preventing human errors has many benefits as it leads to increasing quality, safety and productivity as well as reducing cost, waste and time. The idea of applying (human) error prevention techniques to industrial and organizational processes is referred to as “poke-yoke”. Poka-yoke is the Japanese equivalent of “mistake-proofing” which was first introduced by Shigeo Shingo in the 1960s to prevent human errors in industrial activities. Poka-yoke aims to eliminate defects at the source by designing processes so that mistakes can be immediately detected and corrected [1]. One of the crucial types of error which causes a significant source of public health concern is medical errors. Medical errors are defined as the problems that occur while providing healthcare which lead to failure to complete a planned action as intended or using a wrong action plan to achieve a goal. Such problems include improper transfusion, patient identification errors and adverse drug events [2]. Kohn, et. al, published a report on the effect of medical errors in late 1999 in order to draw attention to the astounding amount of cost and the number of lives lost attributed to medical errors. From two major studies, they estimated that at least 44,000 patients and nearly 98,000 people died in hospital annually as a result of preventable medical errors. In addition, they estimated that medical errors that could have been prevented resulted in total costs of at least $17 billion and almost $29 billion per year in hospitals across the United States. With regards to medication errors (which is one of the various forms of medical errors), they were estimated to lead to the death of 7,000 people [2]. The occurrence of these errors included all phases of drug-use process such as ordering, transcribing, dispensing, and administration