Latest / The Operations Podcast with Fexingo: Process, People, and Profit in Modern Business / How One Hospital Pharmacy Cut Medication Errors by 75 Percent
Transcript
- Lucas: So we all know the statistic: preventable medical errors are the third leading cause of death in the United States. But there's a specific subset of those that rarely gets talked about outside hospital walls, and that's medication errors in hospital pharmacies. Luna: Right — wrong drug, wrong dose, wrong patient, wrong time. It's not just a safety issue; it's an operations problem. Lucas: Exactly. And the numbers are sobering. A 2023 study in the Journal of Patient Safety found that medication errors occur in about one in every twenty hospital admissions. That's roughly 7 million errors a year in the US alone. Luna: And most of those are preventable. Lucas: Most. So the question is: why aren't hospitals fixing this? And the answer, as with so many operations problems, is that it's not about technology — it's about process. And today I want to talk about a hospital that actually did fix it. Luna: Which hospital? Lucas: Mercy Health in Cincinnati. Specifically, their flagship hospital, which runs a pharmacy that fills about 4,000 medication orders a day. Back in 2023, they had a medication error rate of about 0.3 percent. That sounds low, right? But 0.3 percent of 4,000 is twelve errors a day. Some of those are harmless — a vitamin given five minutes late. But some are not. Luna: Twelve errors a day. That's a lot when you think about the cumulative harm over a year. Lucas: Right. And the pharmacy director, a guy named David Chen, decided that was unacceptable. So he and his team launched a project they called 'Zero Harm' — which is a typical hospital name, but the approach was anything but typical. They didn't buy fancy robots or new software. They changed the physical layout of the pharmacy and the sequence of steps in their workflow. Luna: So a lean operations play, basically. Lucas: Exactly. They started by mapping the entire process from the moment a physician writes an order to the moment the medication reaches the patient. And they found that the pharmacy itself was a bottleneck. The layout had the IV preparation station right next to the oral medication dispensing area. So you'd have a pharmacist mixing a chemotherapy drug, and six feet away, someone was counting out aspirin tablets. The risk of cross-contamination or mix-up was built into the floor plan. Luna: That sounds like a recipe for disaster. Lucas: It was. So they redesigned the space. They created a 'clean room' for IV compounding that was physically separated from the rest of the pharmacy. They put in a one-way flow: medications entered at one end, got checked and prepared in the middle, and exited at the other end. No backtracking, no crossing paths. Luna: And they did this without major construction? I'm guessing they didn't knock down walls. Lucas: That's the best part. They used tape on the floor. Seriously. They marked out lanes and zones with colored tape. They moved shelving units and workstations that were on wheels. The whole reconfiguration cost less than $5,000. Luna: Wow. So this is a classic example of a low-cost, high-impact operational change. Lucas: Exactly. But the layout was just the first layer. The second layer was barcode scanning. Now, barcode scanning in hospitals is not new, but it's often implemented poorly. Mercy Health had been using it for years, but the compliance rate was only about 65 percent. Pharmacists would skip scanning because it added a few seconds per order. Luna: Right — the classic tension between speed and safety. Lucas: So Chen's team did something clever. They made scanning a hard stop: if you didn't scan the medication and the patient's wristband, the system simply wouldn't let you proceed. No override. That sounds draconian, but it worked. Within three months, scanning compliance hit 99.7 percent. Luna: And did that reduce errors? Lucas: Dramatically. The error rate dropped from 0.3 percent to 0.08 percent. That's a 73 percent reduction. But here's the thing — they caught something else. Because every scan was recorded, they had data on near-misses. For every actual error that reached a patient, there were about 15 near-misses that were caught in time. And those near-misses pointed to specific patterns. Luna: Patterns like what? Lucas: The most common near-miss was look-alike, sound-alike medications. Drugs with similar names like 'hydralazine' and 'hydroxyzine' — one is a blood pressure drug, the other is an antihistamine. They were being stored next to each other on the shelf. So the team moved them to separate locations and added visual alerts on the bins. Luna: That's such a simple fix. Why didn't they do it earlier? Lucas: Because they didn't have the data. Before the forced scanning, they didn't know where the near-misses were happening. The data revealed the problem, and the fix was trivial. But the third layer is what I think is the most interesting: the daily huddle. Luna: A daily huddle? In a pharmacy? Lucas: Every morning at 7:15 AM, the entire pharmacy team — pharmacists, technicians, even the janitorial staff — gathers for a 10-minute stand-up. They review every error and near-miss from the previous 24 hours. Not to blame anyone, but to ask: what broke in the process? And then they assign a fix to someone right there. Luna: So it's a continuous improvement loop, like a Toyota production system. Lucas: Exactly. And it created a culture where people weren't afraid to report mistakes. In fact, they were encouraged to. Because a near-miss that gets reported is a chance to fix a hole in the system before someone gets hurt. Luna: I'm curious about the human side. When you force a scanning compliance system, there's usually pushback. How did they handle that? Lucas: There was pushback, especially from veteran pharmacists who felt like the system was questioning their competence. David Chen told me about one pharmacist who had been there for 25 years and said, 'I don't need a computer to tell me if I'm giving the right drug.' Chen's response was: 'I know you're good, but the system isn't about you — it's about the one time you're distracted, or tired, or you get interrupted. And that one time could kill someone.' Luna: That's a powerful framing. It's not about distrust; it's about designing for human fallibility. Lucas: Right. And eventually, that pharmacist became one of the biggest advocates for the system. Because she realized that the barcode scan actually saved her from making a mistake when she was exhausted during a night shift. Luna: So the results — 73 percent reduction in errors — that's over what time period? Lucas: Eighteen months. And they've sustained it. As of June 2026, they're still at that level. And they've expanded the approach to the outpatient pharmacy and the hospital's satellite clinics. Luna: It's interesting that you chose a hospital pharmacy example, because a lot of our listeners might think operations is about factories or warehouses. But this is a service operation with high stakes. Lucas: And the principles are exactly the same: map the process, find the bottleneck, remove waste, add a feedback loop. The only difference is that the cost of failure in a hospital is measured in lives, not just dollars. Luna: Which brings up a bigger question: if this is so simple and so effective, why isn't every hospital doing it? Lucas: That's the million-dollar question. And the answer is that it's not really about the cost or the technology. It's about leadership and culture. Mercy Health's CEO made patient safety the top strategic priority. He personally attended the daily huddles once a month. He allocated budget for the tape and the shelving. But more importantly, he gave David Chen the authority to make changes without going through a six-month approval process. Luna: So it's top-down support enabling bottom-up improvement. Lucas: Exactly. And that's hard to replicate. But the lesson for any operations leader is: you don't need a massive budget. You need the willingness to look at your own process honestly, and the discipline to fix one thing at a time. Luna: You know, episodes like this make me think about how much of what we talk about here is transferable. The tape-on-the-floor trick — I've seen that used in warehouses, in restaurants, in offices. It's almost a metaphor. Lucas: It is. And it's a reminder that the best operations solutions are often the simplest. But simple doesn't mean easy. It requires people to change habits, which is really hard. Luna: Speaking of habits — we keep this podcast ad-free because we think the content should speak for itself. No sponsors, no commercials. And if these conversations have given you a new way to think about your own work, and you want to support that, you can at buy me a coffee dot com slash fexingo. Lucas: Yeah, it's a small gesture that makes a big difference. Keeps us independent and focused on the stories that matter. Luna: Exactly. So back to Mercy Health — one other thing I found fascinating was their use of 'stop-work authority.' Any employee, from the janitor to the chief pharmacist, can halt the entire medication dispensing line if they see something unsafe. Lucas: That's huge. And it's borrowed directly from nuclear power plants and aviation. In those industries, if a worker sees a problem, they have the authority — and the obligation — to stop the line. Mercy Health adopted that same principle. And in the first year, it was used about thirty times. Each time, it stopped a potential error. Luna: And management didn't punish people for using it? Lucas: No. In fact, they celebrated it. They put a 'stop-work champion' award on the wall. Because every time someone stops the line, it's a learning opportunity. Luna: That's a culture shift. Most organizations talk about safety but penalize the people who slow things down. Lucas: Right. And that's why so many improvement efforts fail. The technical solution is easy. The cultural change is the hard part. Luna: So if someone listening wants to try something like this in their own organization, what's the first step? Lucas: Start with the near-misses. Most organizations don't track near-misses at all. But every near-miss is a free lesson. Collect them for a week. Put a box in the break room. Make it anonymous. Then look for patterns. That's what Mercy Health did, and it cost them nothing. Luna: And then fix the simplest pattern first. Lucas: Yes. Don't try to fix everything at once. Pick one thing — like moving two medications that look alike — and do it today. Not next week. Today. Luna: That's actionable. I like that. Lucas: So to wrap this up: Mercy Health's pharmacy isn't a high-tech marvel. It's a testament to the fact that operations improvement is 90 percent behavior and 10 percent tools. And that the biggest barrier to better operations is often our own assumption that it's too hard or too expensive. Luna: Or that we need a consultant to tell us what to do. Lucas: Exactly. The answers are usually right in front of us. We just need to look.