Artificial Intelligence-Assisted Quality Control Circles Led by Clinical Pharmacists to Improve the Rational Use of Injectable Proton Pump Inhibitors in Hospitalised Patients

Artificial Intelligence-Assisted Quality Control Circles Led by Clinical Pharmacists to Improve the Rational Use of Injectable Proton Pump Inhibitors in Hospitalised Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Artificial Intelligence-Assisted Quality Control Circles Led by Clinical Pharmacists to Improve the Rational Use of Injectable Proton Pump Inhibitors in Hospitalised Patients Ming Zhang, Wei-cheng Ma, Wen-yue He This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6012541/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Aug, 2025 Read the published version in Scientific Reports → Version 1 posted 25 You are reading this latest preprint version Abstract Proton pump inhibitors (PPIs) are a class of drugs that inhibit gastric acid secretion, and their overuse in clinical practice are relativity common. We developed a quality control circles (QCC) assisted by artificial intelligence (AI) and led by clinical pharmacists to improve the rational use of (PPIs) among hospitalised patients at our hospital. A QCC team was established to follow QCC procedures. The root causes of inappropriate use were identified using AI-assisted brainstorming, and corresponding strategies were developed. The rational use rates of injectable PPIs before and after QCC implementation were calculated and compared. After QCC implementation, the rational use rate of injectable PPIs among hospitalised patients in our hospital increased from 66.51–93.43%, with a goal achievement rate of 126.92% and a progression rate of 40.47%. The increase in the rational use rate of PPIs was statistically significant (P < 0.001). Additionally, team cohesion, responsibility and proficiency in QCC techniques improved after QCC implementation. Furthermore, the standardised process for using injectable PPIs became more regulated after QCC implementation. AI-assisted, clinical pharmacist-led QCCs can serve as an efficient management tool for improving the rational use of injectable PPIs in hospitalised patients, thereby advancing the work of rational drug use in clinics. Health sciences/Medical research Health sciences/Medical research/Drug development Quality Control Circles (QCC) Proton Pump Inhibitors (PPIs) Artificial Intelligence (AI) Rational Drug Use Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Proton pump inhibitors (PPIs) are a class of drugs that specifically block the H+/K + ATPase enzyme (proton pump) located on the apical membrane of gastric parietal cells, thereby inhibiting gastric acid secretion. Compared with histamine H2 receptor antagonists, PPIs provide a more complete and longer-lasting acid suppression effect, with an action duration of 16–18 hours, effectively controlling both basal and meal-stimulated gastric acid secretion 1 . Currently, PPIs have replaced histamine H 2 -receptor antagonists as the first-line treatment for conditions associated with excessive gastric acid secretion, particularly gastroesophageal reflux disease (GERD) 2 . In recent years, with the global increase in PPI usage 3 , concerns have also increased regarding the inappropriate use of PPI formulations. It has been reported that more than 50% of PPI use is inappropriate, meaning that the clinical indications for over half of PPI use do not align with guidelines or expert consensus recommendations 4 . The long-term overuse of PPIs not only increases national healthcare costs but also significantly increases the incidence of adverse drug reactions, causing substantial harm to patients 5,6 . Therefore, improving the rational use of PPIs has become an urgent issue that healthcare institutions need to address. Quality control circles (QCCs), which were originally used in Japan for corporate management and business operations, serve as tools for process management and problem-solving 7 . QCCs leverage the strengths of all participants while fostering interdepartmental collaboration, simplifying complex issues, and ultimately resolving challenges related to institutional operations and management 8 . Since their introduction into Chinese healthcare institutions in 2001, QCCs have been used to identify and solve medical problems, thereby improving the quality of healthcare services in China 9 . ChatGPT, an AI developed by OpenAI in November 2022, uses big data analysis to answer a wide range of user queries and can be employed to enhance brainstorming during QCCs by fostering divergent thinking. In this project, we used AI-assisted, clinical pharmacist-led QCCs to improve the rational use of injectable PPIs among hospitalised patients in large public medical institutions in China. Results Effectiveness Verification of Measures for Insufficient Pre-prescription Review Capacity of Pharmacists The results (Table 1 ) indicate that the rate of intercepting irrational PPI injection prescriptions significantly improved after the implementation of the countermeasures. A rank-sum test analysis comparing the rates of intercepting irrational PPI prescriptions before and after countermeasures revealed a significant increase (P < 0.001). Table 1 Interception rates of inappropriate PPI injection prescriptions before and after countermeasure implementation. Number of prescriptions approved by reviewing pharmacists Number of inappropriate PPIs injection prescriptions intercepted by reviewing pharmacists Total count Interception rate Before the implementation of countermeasures (2024.1.15-2024.1.30 43754 35 43789 0.08% After the implementation of countermeasures (2024.2.7-2024.2.22) 37961 79 38040 0.21% Chi-square 23.88 P < 0.001 Effectiveness Verification of Measures for Inadequate Understanding of Indications for Injectable PPIs The results (Table 2 ) indicate that the rational use rate of injectable PPIs significantly increased after the implementation of the countermeasures. A rank-sum test analysis comparing rational use rates before and after countermeasures revealed a significant improvement (P < 0.05). Table 2 Appropriate rate of PPI injection prescriptions before and after the implementation of countermeasures. Number of appropriate PPIs injection cases Number of inappropriate PPIs injection cases Total number of cases Appropriateness rate Before the implementation of countermeasures (2024.2.23-2024.3.8) 214 72 286 74.82% After the implementation of countermeasures (2024.3.29-2024.4.12) 228 47 275 82.90% Chi-square 5.482 P 0.0192 Effectiveness Verification of Measures for Lack of Intelligent Management in Prescription Orders The results (Table 3 ) demonstrate that the rational use rate of injectable PPIs significantly improved after the implementation of the countermeasures. A rank-sum test analysis comparing the rational use rates before and after countermeasures revealed a significant increase (P < 0.01). Table 3 Appropriate rates of PPI injection before and after the implementation of countermeasures. Number of appropriate PPIs injection cases Number of inappropriate PPIs injection cases Total number of cases Appropriateness rate Before the implementation of countermeasures (2024.4.13-2024.4.27) 228 50 278 82.01% After the implementation of countermeasures (2024.5.13-2024.5.27) 207 20 227 91.19% Chi-square 8.810 P 0.003 Effectiveness Verification of QCC Implementation The evaluation results of PPI injections at our hospital before and after QCC implementation are shown in Fig. 1 A. After QCC implementation, the rational use rate of PPIs increased to 93.43% from 66.51% before QCC implementation, with a statistically significant difference (P < 0.01). Additionally, the target achievement rate for QCC was 126.92%, and the improvement rate was 40.47%. Figure 1 B shows a radar chart indicating that all QCC members experienced growth in various competencies as a result of this QCC. Furthermore, Figs. 1 C–D confirm the significant improvement in the two error types—"inappropriate indications" and "inappropriate dosage and administration"—for injectable PPIs. The process flowcharts for the use of injectable PPIs after QCC implementation are shown in Fig. 2 . After QCC implementation, the PPI use process was enhanced with the addition of an intelligent management system. The system improved the control over PPI indications, dosage and duration, significantly reducing prescription errors related to these aspects. Discussion As a new generation of acid-suppressing medications, PPIs have been in clinical use for more than 20 years. They are widely used to treat conditions such as gastroesophageal reflux disease (GERD), acid-related diseases, erosive gastritis, gastrointestinal strictures and Barrett's oesophagus as well as to prevent gastrointestinal bleeding caused by nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids 2,10 . In the past decade, the use of PPIs has increased annually, with many countries even classifying PPIs as over-the-counter (OTC) drugs, leading to widespread long-term misuse without indications 4,11,12 . Studies have shown that long-term misuse of PPIs is associated with adverse reactions, which can be classified into two categories: acid- and nonacid-related reactions. Acid-related adverse effects include gastrointestinal infections; pneumonia; deficiencies in nutrients, such as calcium, iron, magnesium and vitamin B12; fractures; primary peritonitis; and small intestine bacterial overgrowth. Nonacid-related adverse effects include allergic reactions, acute interstitial nephritis, chronic kidney disease and cardiovascular events 13 . Therefore, long-term misuse of PPIs poses significant safety risks. Additionally, studies indicate a clear correlation between the irrational use of PPIs and increased treatment costs. Global misuse of PPIs is estimated to incur an annual cost of approximately £2 billion, representing a substantial financial burden on both patients and healthcare systems 14 . Quality Control Circles (QCCs) are effective management tools in healthcare institutions used to address various issues encountered in clinical activities. Brainstorming is a crucial component of the QCC process, encompassing key steps such as topic selection, cause analysis and countermeasure development. Traditionally, brainstorming relies heavily on the divergent thinking of QCC members, and the outcomes are often limited by the cognitive abilities of team members. Artificial intelligence tools such as ChatGPT can analyse large datasets based on user-defined prompts and answer related professional questions. This capability is particularly useful in the brainstorming phase of QCCs, as AI can complement the results of traditional brainstorming sessions by providing a comprehensive and efficient analysis of related factors and proposing solutions. This project represents the first application of AI tools to assist in QCCs led by clinical pharmacists, aimed at improving the rational use of injectable PPIs among hospitalised patients in tertiary public hospitals. The results revealed that after QCC implementation, the rational use rate of injectable PPIs among patients in our hospital increased from 66.51–93.4%, with a target achievement rate of 126.92% and an improvement rate of 40.47%. A comparison of the rational use rates of injectable PPIs before and after QCC implementation revealed a significant difference (P < 0.01), indicating a marked improvement in the rational use of PPIs following QCC intervention. In addition to tangible improvements, QCC implementation led to intangible benefits, such as fully engaging the potential and capabilities of all team members and enhancing interdepartmental collaboration 15 . Consistent with this, the radar chart in Fig. 6 B shows that the QCC members’ competencies—such as QCC techniques, team responsibility, cohesion, confidence, problem-solving and communication skills—were significantly improved after QCC implementation. Furthermore, the standardisation of the PPI injection process was enhanced post-QCC, with the introduction of an intelligent management system for prescription orders, resulting in a more standardised and rational process for prescribing PPIs in our hospital. Despite the significant improvements achieved through QCC intervention, certain limitations still exist. As clinical trials continue, the indications for PPI use are subject to ongoing updates. Therefore, continually optimising existing strategies, particularly rational drug use decision support systems and intelligent management systems for PPI injection prescriptions, is essential to increase their regulatory effectiveness. In summary, Quality Control Circles (QCC teams) led by clinical pharmacists, with the assistance of artificial intelligence, can serve as efficient management tools for rational drug use in clinical settings. This approach effectively improves the rational use rate of injectable PPIs among hospitalised patients, thereby advancing the progress of rational medication practices. Methods Data collection Data were collected on all inpatient PPI injection prescriptions at our hospital from November to December 2023 (before QCC implementation) and from June to July 2024 (after QCC implementation). Complete case records were available for all patients and informed consent was obtained from all subjects and/or their legal guardian(s). All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by ethics committee of Ningbo Yinzhou NO.2 Hospital. The ethics approval number is Yin Er Lun Review 2024 reasearch approval No. 081 Topic Selection A random sample of 1290 cases was selected from hospitalised patients in our hospital who were prescribed injectable PPIs (including omeprazole, pantoprazole, esomeprazole, lansoprazole and liarozole) from October 2023 to August 2024. The initial assessment revealed a compliance rate of 66.51%. A QCC team, consisting of six members (four clinical pharmacists, one member from the Medical Affairs Department and one from the Information Technology Department) was formed, and one AI participant (ChatGPT) was involved only in brainstorming and not in the actual project implementation. Based on preliminary discussions and brainstorming results, combined with the L-type matrix method, the goal of this QCC was to improve the rational use rate of injectable PPIs in hospitalised patients. Activity Planning Before activities started, the tasks and responsibilities were assigned based on each team member’s work capabilities and the content of each project phase. The activities were scheduled in a chronological sequence, and a Gantt chart was used to monitor and control the progress. As shown in Fig. 3 , the planning phase (P), implementation phase (D), checking and evaluation phase (C) and summary and assessment phase (A) accounted for approximately 30%, 40%, 20% and 10% of the total activity duration, respectively. Development of a Process Flowchart Related to the Topic The QCC team held a meeting to thoroughly discuss and review the clinical use process of injectable PPIs, resulting in the development of a process flowchart for the use of injectable PPIs in hospitalised patients (Fig. 4 ). Because this activity was led by clinical pharmacists, the improvement focus was on three key processes: indications for PPI use met, prescription of PPIs issued and pharmacists’ prescription review. Collection of Baseline Data Clinical pharmacists used rational drug use software to extract all PPI injection cases at our hospital from November to December 2023, a total of 1290 cases. A specialised review team evaluated these cases based on drug labels, domestic and international guidelines and expert consensus. The clinical pharmacists collected the review results, calculated the rational use rate of injectable PPIs, and performed a categorised analysis of irrational prescriptions based on error types. The results revealed that the rational use rate of injectable PPIs from November to December 2023 (before QCC implementation) was 66.51% (baseline value). The “Plato analysis” of error types in irrational prescriptions is shown in Fig. 5 . According to the “Plato analysis” principle, "inappropriate indications" and "inappropriate dosage and administration" were identified as the primary focus areas for improvement in this phase (improvement focus, 79.17%). Goal Setting According to the QCC "5-3-1" evaluation method, the QCC team's circle capability was calculated to be 80%. The formula for calculating the target value is as follows: Current value + [(1 - Current value) * Improvement Focus * Circle Capability]. Thus, the target value = 66.51% + [(100% − 66.51%) * 79.17% * 80%], resulting in a calculated target value of 87.72%. Statistical analysis was performed using SPSS 19.0 software, with count data analysed using the rank-sum test. A p-value of < 0.05 was considered to indicate a statistically significant difference. Root Cause Analysis There are numerous reasons for the low rational use rate of injectable PPIs among hospitalised patients. The QCC team conducted a brainstorming session involving all members, combined with search results from ChatGPT (with the query set as follows: "Analyse all reasons for the low rational use rate of injectable proton pump inhibitors in hospitalised patients from the perspectives of personnel, drugs, environment, methods and systems"). This analysis identified five major categories of causes: personnel, drugs, environment, methods and systems. Each major category was further analysed to identify all sub-causes, which were then depicted in a fishbone diagram (Fig. 6 ). Among these, the lack of clarity in PPI use indications and the non-standardisation of PPI use were identified by ChatGPT. After all causes were scored based on their importance using the "5-3-1" evaluation method, the QCC team selected six key factors contributing to the low rational use rate of injectable PPIs: inadequate understanding of PPI indications among physicians, inadequate knowledge base of pharmacists, insufficient pre-prescription review capability of pharmacists, no standardised medication guidelines, lack intelligent management for PPI prescription orders and inadequate prescription review efforts. Verification of Root Causes The six key factors were used to design a survey questionnaire using the 5W1H principle and distributed to various wards for root cause verification. A total of 60 people were surveyed, including 50 physicians and 10 pharmacists. The survey results were analysed and presented in a Pareto chart (Fig. 7 ). Based on the Pareto principle, the survey confirmed that insufficient understanding of PPI use indications, lack of intelligent management for prescription orders and inadequate preliminary review capabilities are the root causes of the low rational use rate of injectable PPIs among hospitalised patients. Development of Countermeasures The QCC team conducted a brainstorming session to develop corresponding countermeasures for the three identified root causes based on the 5W1H principle. The results are shown in Table 4 . The proposed strategies included conducting PPI training for clinical physicians across all hospital wards, recommending the establishment of standardised management protocols for PPI use and creating a preliminary review system for PPI prescriptions. These strategies were provided by ChatGPT based on the query (set as follows: "Propose solutions based on the three identified root causes"). The QCC team then used the "5-3-1" evaluation method to score the proposed countermeasures in terms of feasibility, effectiveness and autonomy. This process helps determine appropriate countermeasures for each root cause and establish the implementation timeline, location and responsible parties. Table 4 The results of the brainstorming session conducted by the QCC team on the three root causes, guided by the 5W1H principle. What Why How Who “5-3-1” score Determination When where Improve the Rational Use of Injectable Proton Pump Inhibitors in Hospitalized Patients Inadequate understanding of PPIs indications among physicians The hospital's clinical pharmacists provided training to all clinicians on the appropriate utilization of PPIs. QCC member 1 90 Yes 2024.3.9-2024.3.28 Clinical departments Create a concise informational card promoting the rational use of PPIs injections within our hospital. QCC member 4 82 Yes 2024.3.9-2024.3.10 Department of Clinical Medicine Clinical pharmacists promptly provide feedback on the off-label administration of PPIs injections in various clinical departments QCC member 1 68 Yes 2024.3.9-2024.3.28 Clinical departments Clinical departments conduct a self-examination of the use of PPIs injections in their departments QCC member 2 52 No Lack of intelligent management for PPIs prescription orders Clinical pharmacists collaborate with the information center to develop a template for prescribing injectable PPIs QCC member 5 78 Yes 2024.4.28-2024.5.12 Information center and department of Clinical Medicine improved the rational drug use database of PPIs injections QCC member 6 88 Yes 2024.4.28-2024.5.12 Department of Clinical Medicine Insufficient pre-prescription review capacity of pharmacists Clinical pharmacists establish the clinical rational use standard of PPIs injections in our hospital QCC member 2 80 Yes 2024.2.1-2024.2.7 Department of Clinical Medicine Clinical pharmacists provide training on the proper use of PPIs injections to reviewing pharmacists QCC member 3 80 Yes 2024.2.1-2024.2.7 Department of Clinical Medicine Pharmacists conducting prescription review training to enhance their prescription review abilities QCC member 5 46 No Implementation of Measures for Insufficient Prescription Review Capacity of Pharmacists Before the implementation of countermeasures, our hospital did not have a unified standard for PPI use, which prevented preliminary review by pharmacists from accurately intercepting incorrect prescriptions according to a standard. The QCC team, which is guided by the "Guidelines for the Clinical Use of Proton Pump Inhibitors (2020 Edition)" issued by the National Health Commission and the "Regulations for the Rational Use of Proton Pump Inhibitors in Ningbo (2021 Edition)" issued by the Ningbo Health Commission, developed clinical use standards for injectable PPIs in our hospital after discussions with clinical physicians. All preliminary review pharmacists were trained on the new standards to enhance their preliminary review capabilities. Implementation of Measures for Inadequate Understanding of PPI Indications Among Physicians Before the implementation of countermeasures, there were issues in our hospital, with internal medicine physicians having an unclear grasp of the indications for injectable PPIs and surgical physicians lacking an understanding of the indications for PPI use in surgical prophylaxis. To address these issues, the QCC team created small tip cards outlining the newly established indications for injectable PPIs, which were distributed to all physicians to be placed on their white coats. This initiative aimed to increase physicians’ understanding of the indications for injectable PPIs. Additionally, the QCC members conducted training on the rational use of PPIs for key departments in our hospital, providing feedback on irrational use cases to improve the understanding of PPI indications among physicians in various departments. Implementation of Measures for Lack of Intelligent Management in Prescription Orders Before the countermeasures were implemented, several shortcomings in the prescription of injectable PPIs by physicians were noted. (1) There were no fasting reminders in the prescription orders, leading to injectable PPIs being prescribed to patients who could take oral medication. (2) There were no reminders for indications of injectable PPIs, resulting in many injections being prescribed without appropriate indications. (3) The rational drug use database was incomplete, leading to a lack of intelligent control over dosage, administration, and duration, resulting in incorrect dosing and prolonged treatment with injectable PPIs. To address these issues, the QCC team, in collaboration with our hospital’s Information Center, developed a template for prescribing injectable PPIs. This template automatically checks for fasting orders when a PPI injection is prescribed, and if no fasting is indicated, the physician is prompted to consider oral PPIs instead. Additionally, when prescribing injectable PPIs, the template requires physicians to select the corresponding indications based on risk factors or treatment needs, thereby standardising the use of injectable PPIs. Furthermore, the QCC team improved the rational drug use database, enabling rational drug use software to provide intelligent reminders and control over the dosage, administration and duration of injectable PPIs. Effectiveness Verification After the implementation of all countermeasures, a total of 731 cases of injectable PPIs in our hospital from June to July 2024 were collected via rational drug use software for rational drug use comments. These results were compared with the pre-QCC implementation results. The target achievement and improvement rates were calculated, and Pareto charts, process flowcharts and radar charts were created to visualise the changes before and after QCC implementation. Target Achievement Rate = (appropriateness rate of PPI injection use after improvement - appropriateness rate of PPI injection use before improvement)/(target appropriateness rate of PPI injection use - appropriateness rate of PPI injection use before improvement) *100% Improvement Rate = (appropriateness rate of PPI injection use after improvement - appropriateness rate of PPI injection use before improvement)/(appropriateness rate of PPI injection use before improvement) *100% Declarations Funding This research was supported by Ningbo Natural Science Foundation (Grant No. 2024J363) Disclosure of interest No potential conflict of interest was reported by the authors Data availability statement The data that support the findings of this study are available from the first author, Ming Zhang, upon reasonable request. References Meng, X. et al. 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Annals of palliative medicine 10 , 11558-11565 (2021). https://doi.org/10.21037/apm-21-2644 Strand, D. S., Kim, D. & Peura, D. A. 25 Years of Proton Pump Inhibitors: A Comprehensive Review. Gut and liver 11 , 27-37 (2017). https://doi.org/10.5009/gnl15502 Inadomi, J. M. & Fendrick, A. M. PPI use in the OTC era: who to treat, with what, and for how long? Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 3 , 208-215 (2005). https://doi.org/10.1016/s1542-3565(04)00717-7 Yadlapati, R. & Kahrilas, P. J. When is proton pump inhibitor use appropriate? BMC medicine 15 , 36 (2017). https://doi.org/10.1186/s12916-017-0804-x Dharmarajan, T. S. The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing. Journal of the American Medical Directors Association 22 , 15-22 (2021). https://doi.org/10.1016/j.jamda.2020.09.046 Forgacs, I. & Loganayagam, A. Overprescribing proton pump inhibitors. BMJ (Clinical research ed.) 336 , 2-3 (2008). https://doi.org/10.1136/bmj.39406.449456.BE Lin, L. et al. Sustained accuracy improvement in intraocular lens power calculation with the application of quality control circle. Scientific reports 7 , 14852 (2017). https://doi.org/10.1038/s41598-017-14171-9 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Aug, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 22 Apr, 2025 Reviews received at journal 21 Apr, 2025 Reviews received at journal 18 Apr, 2025 Reviews received at journal 12 Apr, 2025 Reviews received at journal 11 Apr, 2025 Reviews received at journal 08 Apr, 2025 Reviews received at journal 07 Apr, 2025 Reviews received at journal 04 Apr, 2025 Reviewers agreed at journal 04 Apr, 2025 Reviewers agreed at journal 03 Apr, 2025 Reviewers agreed at journal 03 Apr, 2025 Reviewers agreed at journal 03 Apr, 2025 Reviewers agreed at journal 03 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviewers agreed at journal 02 Apr, 2025 Reviewers agreed at journal 01 Apr, 2025 Reviewers agreed at journal 01 Apr, 2025 Reviewers invited by journal 01 Apr, 2025 Editor assigned by journal 01 Apr, 2025 Editor invited by journal 13 Feb, 2025 Submission checks completed at journal 13 Feb, 2025 First submitted to journal 12 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6012541","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":415416201,"identity":"b420d02a-cad1-4e1c-ac4b-f725dad752d2","order_by":0,"name":"Ming Zhang","email":"","orcid":"","institution":"Ningbo Yinzhou NO.2 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Zhang","suffix":""},{"id":415416202,"identity":"66014f68-391e-43c4-a364-38674bca7eb7","order_by":1,"name":"Wei-cheng Ma","email":"","orcid":"","institution":"Ningbo Yinzhou NO.2 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei-cheng","middleName":"","lastName":"Ma","suffix":""},{"id":415416203,"identity":"17f1bcf8-a806-4f81-b13e-371d3788b8cf","order_by":2,"name":"Wen-yue He","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYFACHvYfCQY1dmzsjY0PPxCphUHiQcWxZD6ew83GEsRqkXxwhplxnkR6mwAPMRoMbuQeMEhsY2Nmk3zYxiDBYCen20BQS15CQmKbDB+bdGLbgwKGZGOzAwS0mN3IMTgAtkU6sd1AguFA4jYitBg2JLYxM7ZJHmyT4CFSizFDAtD7bRKMRGqxP/PGjCEBGMhsPInAQDYgwi+S7TlmjD+AUSnffvzhww8VdnIEtTAIJCDzDAgpBwF+goaOglEwCkbBiAcA1BpBnxCCNuUAAAAASUVORK5CYII=","orcid":"","institution":"Ningbo Yinzhou NO.2 Hospital","correspondingAuthor":true,"prefix":"","firstName":"Wen-yue","middleName":"","lastName":"He","suffix":""}],"badges":[],"createdAt":"2025-02-12 06:53:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6012541/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6012541/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-16934-1","type":"published","date":"2025-08-26T15:58:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":76571871,"identity":"3ee3ec00-42a5-42d1-a2c2-34f01e7eca92","added_by":"auto","created_at":"2025-02-18 13:45:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":384311,"visible":true,"origin":"","legend":"\u003cp\u003eQCC effectiveness verification results.\u003c/p\u003e\n\u003cp\u003eA. Evaluation results of PPI injection before and after QCC implementation. B. Radar chart depicting the statistical results of various competencies of QCC members before and after implementation. Pareto analysis results of inappropriate PPI injection prescription types before (C) and after (D) QCC implementation.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-6012541/v1/0d8fab941a0196f30beff292.png"},{"id":76571873,"identity":"9b643ad6-aa52-401c-82e4-1f6ceee7d799","added_by":"auto","created_at":"2025-02-18 13:45:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":364582,"visible":true,"origin":"","legend":"\u003cp\u003eProcess flowcharts for the use of injectable PPIs after QCC implementation.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-6012541/v1/e82a28ffc8c5c5bd5346c43c.png"},{"id":76571887,"identity":"0444c5e6-54c8-4598-9139-876a2d9883d7","added_by":"auto","created_at":"2025-02-18 13:45:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":27418,"visible":true,"origin":"","legend":"\u003cp\u003ethe QCC schedule developed by the “Gantt chart”.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6012541/v1/0991a70566f23c011408be7d.png"},{"id":76573063,"identity":"ab670da5-9263-4592-bf2b-938d10b0483c","added_by":"auto","created_at":"2025-02-18 13:53:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":573217,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of PPI injection use process for hospitalised patients.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-6012541/v1/ed69f59bfd817680a6831073.png"},{"id":76571894,"identity":"398c14f9-1d0a-4c54-a0dc-e8679ce7ec6c","added_by":"auto","created_at":"2025-02-18 13:45:41","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":243833,"visible":true,"origin":"","legend":"\u003cp\u003eThe “Plato analysis” of the error types in irrational PPIs prescriptions.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-6012541/v1/577767de77502d10178e2f3b.png"},{"id":76571880,"identity":"699306cb-6c66-430d-8122-dfd6c1ad436b","added_by":"auto","created_at":"2025-02-18 13:45:40","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":548703,"visible":true,"origin":"","legend":"\u003cp\u003eThe fishbone diagram of reasons for low appropriateness of PPI injection use among hospitalised patients.\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-6012541/v1/f898e531660c561af35737f9.png"},{"id":76571872,"identity":"cca90842-fcd3-4972-9b1d-fa4b594d8e1c","added_by":"auto","created_at":"2025-02-18 13:45:40","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":309299,"visible":true,"origin":"","legend":"\u003cp\u003eThe “Plato analysis” of the root cause verification results.\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-6012541/v1/db945ca711a46d5b17dd932e.png"},{"id":90344972,"identity":"472fe0e1-369d-43e9-b6a4-a934f26053ce","added_by":"auto","created_at":"2025-09-01 16:08:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3492512,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6012541/v1/48c6b0c9-6e09-4129-be9e-4c31f914ffd2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Artificial Intelligence-Assisted Quality Control Circles Led by Clinical Pharmacists to Improve the Rational Use of Injectable Proton Pump Inhibitors in Hospitalised Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProton pump inhibitors (PPIs) are a class of drugs that specifically block the H+/K\u0026thinsp;+\u0026thinsp;ATPase enzyme (proton pump) located on the apical membrane of gastric parietal cells, thereby inhibiting gastric acid secretion. Compared with histamine H2 receptor antagonists, PPIs provide a more complete and longer-lasting acid suppression effect, with an action duration of 16\u0026ndash;18 hours, effectively controlling both basal and meal-stimulated gastric acid secretion\u003csup\u003e1\u003c/sup\u003e. Currently, PPIs have replaced histamine H\u003csub\u003e2\u003c/sub\u003e-receptor antagonists as the first-line treatment for conditions associated with excessive gastric acid secretion, particularly gastroesophageal reflux disease (GERD)\u003csup\u003e2\u003c/sup\u003e. In recent years, with the global increase in PPI usage\u003csup\u003e3\u003c/sup\u003e, concerns have also increased regarding the inappropriate use of PPI formulations. It has been reported that more than 50% of PPI use is inappropriate, meaning that the clinical indications for over half of PPI use do not align with guidelines or expert consensus recommendations\u003csup\u003e4\u003c/sup\u003e. The long-term overuse of PPIs not only increases national healthcare costs but also significantly increases the incidence of adverse drug reactions, causing substantial harm to patients\u003csup\u003e5,6\u003c/sup\u003e. Therefore, improving the rational use of PPIs has become an urgent issue that healthcare institutions need to address.\u003c/p\u003e \u003cp\u003eQuality control circles (QCCs), which were originally used in Japan for corporate management and business operations, serve as tools for process management and problem-solving \u003csup\u003e7\u003c/sup\u003e. QCCs leverage the strengths of all participants while fostering interdepartmental collaboration, simplifying complex issues, and ultimately resolving challenges related to institutional operations and management\u003csup\u003e8\u003c/sup\u003e. Since their introduction into Chinese healthcare institutions in 2001, QCCs have been used to identify and solve medical problems, thereby improving the quality of healthcare services in China\u003csup\u003e9\u003c/sup\u003e. ChatGPT, an AI developed by OpenAI in November 2022, uses big data analysis to answer a wide range of user queries and can be employed to enhance brainstorming during QCCs by fostering divergent thinking. In this project, we used AI-assisted, clinical pharmacist-led QCCs to improve the rational use of injectable PPIs among hospitalised patients in large public medical institutions in China.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness Verification of Measures for Insufficient Pre-prescription Review Capacity of Pharmacists\u003c/h2\u003e \u003cp\u003eThe results (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) indicate that the rate of intercepting irrational PPI injection prescriptions significantly improved after the implementation of the countermeasures. A rank-sum test analysis comparing the rates of intercepting irrational PPI prescriptions before and after countermeasures revealed a significant increase (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterception rates of inappropriate PPI injection prescriptions before and after countermeasure implementation.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of prescriptions approved by reviewing pharmacists\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of inappropriate PPIs injection prescriptions intercepted by reviewing pharmacists\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal count\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterception rate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore the implementation of countermeasures (2024.1.15-2024.1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43754\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43789\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.08%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter the implementation of countermeasures (2024.2.7-2024.2.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChi-square\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEffectiveness Verification of Measures for Inadequate Understanding of Indications for Injectable PPIs\u003c/h3\u003e\n\u003cp\u003eThe results (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) indicate that the rational use rate of injectable PPIs significantly increased after the implementation of the countermeasures. A rank-sum test analysis comparing rational use rates before and after countermeasures revealed a significant improvement (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAppropriate rate of PPI injection prescriptions before and after the implementation of countermeasures.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of appropriate PPIs injection cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of inappropriate PPIs injection cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal number of cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAppropriateness rate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore the implementation of countermeasures (2024.2.23-2024.3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e74.82%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter the implementation of countermeasures (2024.3.29-2024.4.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e82.90%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChi-square\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eEffectiveness Verification of Measures for Lack of Intelligent Management in Prescription Orders\u003c/h3\u003e\n\u003cp\u003eThe results (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) demonstrate that the rational use rate of injectable PPIs significantly improved after the implementation of the countermeasures. A rank-sum test analysis comparing the rational use rates before and after countermeasures revealed a significant increase (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAppropriate rates of PPI injection before and after the implementation of countermeasures.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of appropriate PPIs injection cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of inappropriate PPIs injection cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal number of cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAppropriateness rate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore the implementation of countermeasures\u003c/p\u003e \u003cp\u003e(2024.4.13-2024.4.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e82.01%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter the implementation of countermeasures\u003c/p\u003e \u003cp\u003e(2024.5.13-2024.5.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e91.19%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChi-square\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eEffectiveness Verification of QCC Implementation\u003c/h3\u003e\n\u003cp\u003eThe evaluation results of PPI injections at our hospital before and after QCC implementation are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA. After QCC implementation, the rational use rate of PPIs increased to 93.43% from 66.51% before QCC implementation, with a statistically significant difference (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Additionally, the target achievement rate for QCC was 126.92%, and the improvement rate was 40.47%. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB shows a radar chart indicating that all QCC members experienced growth in various competencies as a result of this QCC. Furthermore, Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC\u0026ndash;D confirm the significant improvement in the two error types\u0026mdash;\"inappropriate indications\" and \"inappropriate dosage and administration\"\u0026mdash;for injectable PPIs.\u003c/p\u003e \u003cp\u003eThe process flowcharts for the use of injectable PPIs after QCC implementation are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. After QCC implementation, the PPI use process was enhanced with the addition of an intelligent management system. The system improved the control over PPI indications, dosage and duration, significantly reducing prescription errors related to these aspects.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs a new generation of acid-suppressing medications, PPIs have been in clinical use for more than 20 years. They are widely used to treat conditions such as gastroesophageal reflux disease (GERD), acid-related diseases, erosive gastritis, gastrointestinal strictures and Barrett's oesophagus as well as to prevent gastrointestinal bleeding caused by nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids \u003csup\u003e2,10\u003c/sup\u003e. In the past decade, the use of PPIs has increased annually, with many countries even classifying PPIs as over-the-counter (OTC) drugs, leading to widespread long-term misuse without indications \u003csup\u003e4,11,12\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eStudies have shown that long-term misuse of PPIs is associated with adverse reactions, which can be classified into two categories: acid- and nonacid-related reactions. Acid-related adverse effects include gastrointestinal infections; pneumonia; deficiencies in nutrients, such as calcium, iron, magnesium and vitamin B12; fractures; primary peritonitis; and small intestine bacterial overgrowth. Nonacid-related adverse effects include allergic reactions, acute interstitial nephritis, chronic kidney disease and cardiovascular events\u003csup\u003e13\u003c/sup\u003e. Therefore, long-term misuse of PPIs poses significant safety risks. Additionally, studies indicate a clear correlation between the irrational use of PPIs and increased treatment costs. Global misuse of PPIs is estimated to incur an annual cost of approximately \u0026pound;2\u0026nbsp;billion, representing a substantial financial burden on both patients and healthcare systems\u003csup\u003e14\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eQuality Control Circles (QCCs) are effective management tools in healthcare institutions used to address various issues encountered in clinical activities. Brainstorming is a crucial component of the QCC process, encompassing key steps such as topic selection, cause analysis and countermeasure development. Traditionally, brainstorming relies heavily on the divergent thinking of QCC members, and the outcomes are often limited by the cognitive abilities of team members. Artificial intelligence tools such as ChatGPT can analyse large datasets based on user-defined prompts and answer related professional questions. This capability is particularly useful in the brainstorming phase of QCCs, as AI can complement the results of traditional brainstorming sessions by providing a comprehensive and efficient analysis of related factors and proposing solutions. This project represents the first application of AI tools to assist in QCCs led by clinical pharmacists, aimed at improving the rational use of injectable PPIs among hospitalised patients in tertiary public hospitals.\u003c/p\u003e \u003cp\u003eThe results revealed that after QCC implementation, the rational use rate of injectable PPIs among patients in our hospital increased from 66.51\u0026ndash;93.4%, with a target achievement rate of 126.92% and an improvement rate of 40.47%. A comparison of the rational use rates of injectable PPIs before and after QCC implementation revealed a significant difference (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating a marked improvement in the rational use of PPIs following QCC intervention. In addition to tangible improvements, QCC implementation led to intangible benefits, such as fully engaging the potential and capabilities of all team members and enhancing interdepartmental collaboration \u003csup\u003e15\u003c/sup\u003e. Consistent with this, the radar chart in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eB shows that the QCC members\u0026rsquo; competencies\u0026mdash;such as QCC techniques, team responsibility, cohesion, confidence, problem-solving and communication skills\u0026mdash;were significantly improved after QCC implementation. Furthermore, the standardisation of the PPI injection process was enhanced post-QCC, with the introduction of an intelligent management system for prescription orders, resulting in a more standardised and rational process for prescribing PPIs in our hospital.\u003c/p\u003e \u003cp\u003eDespite the significant improvements achieved through QCC intervention, certain limitations still exist. As clinical trials continue, the indications for PPI use are subject to ongoing updates. Therefore, continually optimising existing strategies, particularly rational drug use decision support systems and intelligent management systems for PPI injection prescriptions, is essential to increase their regulatory effectiveness.\u003c/p\u003e \u003cp\u003eIn summary, Quality Control Circles (QCC teams) led by clinical pharmacists, with the assistance of artificial intelligence, can serve as efficient management tools for rational drug use in clinical settings. This approach effectively improves the rational use rate of injectable PPIs among hospitalised patients, thereby advancing the progress of rational medication practices.\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eData were collected on all inpatient PPI injection prescriptions at our hospital from November to December 2023 (before QCC implementation) and from June to July 2024 (after QCC implementation).\u003c/p\u003e \u003cp\u003eComplete case records were available for all patients and informed consent was obtained from all subjects and/or their legal guardian(s). All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by ethics committee of Ningbo Yinzhou NO.2 Hospital. The ethics approval number is Yin Er Lun Review 2024 reasearch approval No. 081\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eTopic Selection\u003c/h3\u003e\n\u003cp\u003eA random sample of 1290 cases was selected from hospitalised patients in our hospital who were prescribed injectable PPIs (including omeprazole, pantoprazole, esomeprazole, lansoprazole and liarozole) from October 2023 to August 2024. The initial assessment revealed a compliance rate of 66.51%. A QCC team, consisting of six members (four clinical pharmacists, one member from the Medical Affairs Department and one from the Information Technology Department) was formed, and one AI participant (ChatGPT) was involved only in brainstorming and not in the actual project implementation. Based on preliminary discussions and brainstorming results, combined with the L-type matrix method, the goal of this QCC was to improve the rational use rate of injectable PPIs in hospitalised patients.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eActivity Planning\u003c/h2\u003e \u003cp\u003eBefore activities started, the tasks and responsibilities were assigned based on each team member\u0026rsquo;s work capabilities and the content of each project phase. The activities were scheduled in a chronological sequence, and a Gantt chart was used to monitor and control the progress. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the planning phase (P), implementation phase (D), checking and evaluation phase (C) and summary and assessment phase (A) accounted for approximately 30%, 40%, 20% and 10% of the total activity duration, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of a Process Flowchart Related to the Topic\u003c/h2\u003e \u003cp\u003eThe QCC team held a meeting to thoroughly discuss and review the clinical use process of injectable PPIs, resulting in the development of a process flowchart for the use of injectable PPIs in hospitalised patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Because this activity was led by clinical pharmacists, the improvement focus was on three key processes: indications for PPI use met, prescription of PPIs issued and pharmacists\u0026rsquo; prescription review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCollection of Baseline Data\u003c/h2\u003e \u003cp\u003eClinical pharmacists used rational drug use software to extract all PPI injection cases at our hospital from November to December 2023, a total of 1290 cases. A specialised review team evaluated these cases based on drug labels, domestic and international guidelines and expert consensus. The clinical pharmacists collected the review results, calculated the rational use rate of injectable PPIs, and performed a categorised analysis of irrational prescriptions based on error types. The results revealed that the rational use rate of injectable PPIs from November to December 2023 (before QCC implementation) was 66.51% (baseline value). The \u0026ldquo;Plato analysis\u0026rdquo; of error types in irrational prescriptions is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. According to the \u0026ldquo;Plato analysis\u0026rdquo; principle, \"inappropriate indications\" and \"inappropriate dosage and administration\" were identified as the primary focus areas for improvement in this phase (improvement focus, 79.17%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eGoal Setting\u003c/h2\u003e \u003cp\u003eAccording to the QCC \"5-3-1\" evaluation method, the QCC team's circle capability was calculated to be 80%. The formula for calculating the target value is as follows:\u003c/p\u003e \u003cp\u003eCurrent value + [(1 - Current value) * Improvement Focus * Circle Capability].\u003c/p\u003e \u003cp\u003eThus, the target value\u0026thinsp;=\u0026thinsp;66.51% + [(100% \u0026minus;\u0026thinsp;66.51%) * 79.17% * 80%], resulting in a calculated target value of 87.72%.\u003c/p\u003e \u003cp\u003eStatistical analysis was performed using SPSS 19.0 software, with count data analysed using the rank-sum test. A p-value of \u0026lt;\u0026thinsp;0.05 was considered to indicate a statistically significant difference.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRoot Cause Analysis\u003c/h2\u003e \u003cp\u003eThere are numerous reasons for the low rational use rate of injectable PPIs among hospitalised patients. The QCC team conducted a brainstorming session involving all members, combined with search results from ChatGPT (with the query set as follows: \"Analyse all reasons for the low rational use rate of injectable proton pump inhibitors in hospitalised patients from the perspectives of personnel, drugs, environment, methods and systems\"). This analysis identified five major categories of causes: personnel, drugs, environment, methods and systems. Each major category was further analysed to identify all sub-causes, which were then depicted in a fishbone diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Among these, the lack of clarity in PPI use indications and the non-standardisation of PPI use were identified by ChatGPT. After all causes were scored based on their importance using the \"5-3-1\" evaluation method, the QCC team selected six key factors contributing to the low rational use rate of injectable PPIs: inadequate understanding of PPI indications among physicians, inadequate knowledge base of pharmacists, insufficient pre-prescription review capability of pharmacists, no standardised medication guidelines, lack intelligent management for PPI prescription orders and inadequate prescription review efforts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eVerification of Root Causes\u003c/h2\u003e \u003cp\u003eThe six key factors were used to design a survey questionnaire using the 5W1H principle and distributed to various wards for root cause verification. A total of 60 people were surveyed, including 50 physicians and 10 pharmacists. The survey results were analysed and presented in a Pareto chart (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Based on the Pareto principle, the survey confirmed that insufficient understanding of PPI use indications, lack of intelligent management for prescription orders and inadequate preliminary review capabilities are the root causes of the low rational use rate of injectable PPIs among hospitalised patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of Countermeasures\u003c/h2\u003e \u003cp\u003eThe QCC team conducted a brainstorming session to develop corresponding countermeasures for the three identified root causes based on the 5W1H principle. The results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The proposed strategies included conducting PPI training for clinical physicians across all hospital wards, recommending the establishment of standardised management protocols for PPI use and creating a preliminary review system for PPI prescriptions. These strategies were provided by ChatGPT based on the query (set as follows: \"Propose solutions based on the three identified root causes\"). The QCC team then used the \"5-3-1\" evaluation method to score the proposed countermeasures in terms of feasibility, effectiveness and autonomy. This process helps determine appropriate countermeasures for each root cause and establish the implementation timeline, location and responsible parties.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe results of the brainstorming session conducted by the QCC team on the three root causes, guided by the 5W1H principle.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWho\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;5-3-1\u0026rdquo; score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDetermination\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWhen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ewhere\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eImprove the Rational Use of Injectable Proton Pump Inhibitors in Hospitalized Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eInadequate understanding of PPIs indications among physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe hospital's clinical pharmacists provided training to all clinicians on the appropriate utilization of PPIs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e2024.3.9-2024.3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eClinical departments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCreate a concise informational card promoting the rational use of PPIs injections within our hospital.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e2024.3.9-2024.3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDepartment of Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical pharmacists promptly provide feedback on the off-label administration of PPIs injections in various clinical departments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e2024.3.9-2024.3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eClinical departments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical departments conduct a self-examination of the use of PPIs injections in their departments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLack of intelligent management for PPIs prescription orders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical pharmacists collaborate with the information center to develop a template for prescribing injectable PPIs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e2024.4.28-2024.5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInformation center and department of Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eimproved the rational drug use database of PPIs injections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e2024.4.28-2024.5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDepartment of Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eInsufficient pre-prescription review capacity of pharmacists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical pharmacists establish the clinical rational use standard of PPIs injections in our hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e2024.2.1-2024.2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDepartment of Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical pharmacists provide training on the proper use of PPIs injections to reviewing pharmacists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e \u003cp\u003e2024.2.1-2024.2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDepartment of Clinical Medicine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePharmacists conducting prescription review training to enhance their prescription review abilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQCC member 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of Measures for Insufficient Prescription Review Capacity of Pharmacists\u003c/h2\u003e \u003cp\u003eBefore the implementation of countermeasures, our hospital did not have a unified standard for PPI use, which prevented preliminary review by pharmacists from accurately intercepting incorrect prescriptions according to a standard. The QCC team, which is guided by the \"Guidelines for the Clinical Use of Proton Pump Inhibitors (2020 Edition)\" issued by the National Health Commission and the \"Regulations for the Rational Use of Proton Pump Inhibitors in Ningbo (2021 Edition)\" issued by the Ningbo Health Commission, developed clinical use standards for injectable PPIs in our hospital after discussions with clinical physicians. All preliminary review pharmacists were trained on the new standards to enhance their preliminary review capabilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of Measures for Inadequate Understanding of PPI Indications Among Physicians\u003c/h2\u003e \u003cp\u003eBefore the implementation of countermeasures, there were issues in our hospital, with internal medicine physicians having an unclear grasp of the indications for injectable PPIs and surgical physicians lacking an understanding of the indications for PPI use in surgical prophylaxis. To address these issues, the QCC team created small tip cards outlining the newly established indications for injectable PPIs, which were distributed to all physicians to be placed on their white coats. This initiative aimed to increase physicians\u0026rsquo; understanding of the indications for injectable PPIs. Additionally, the QCC members conducted training on the rational use of PPIs for key departments in our hospital, providing feedback on irrational use cases to improve the understanding of PPI indications among physicians in various departments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of Measures for Lack of Intelligent Management in Prescription Orders\u003c/h2\u003e \u003cp\u003eBefore the countermeasures were implemented, several shortcomings in the prescription of injectable PPIs by physicians were noted. (1) There were no fasting reminders in the prescription orders, leading to injectable PPIs being prescribed to patients who could take oral medication. (2) There were no reminders for indications of injectable PPIs, resulting in many injections being prescribed without appropriate indications. (3) The rational drug use database was incomplete, leading to a lack of intelligent control over dosage, administration, and duration, resulting in incorrect dosing and prolonged treatment with injectable PPIs.\u003c/p\u003e \u003cp\u003eTo address these issues, the QCC team, in collaboration with our hospital\u0026rsquo;s Information Center, developed a template for prescribing injectable PPIs. This template automatically checks for fasting orders when a PPI injection is prescribed, and if no fasting is indicated, the physician is prompted to consider oral PPIs instead. Additionally, when prescribing injectable PPIs, the template requires physicians to select the corresponding indications based on risk factors or treatment needs, thereby standardising the use of injectable PPIs. Furthermore, the QCC team improved the rational drug use database, enabling rational drug use software to provide intelligent reminders and control over the dosage, administration and duration of injectable PPIs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness Verification\u003c/h2\u003e \u003cp\u003eAfter the implementation of all countermeasures, a total of 731 cases of injectable PPIs in our hospital from June to July 2024 were collected via rational drug use software for rational drug use comments. These results were compared with the pre-QCC implementation results. The target achievement and improvement rates were calculated, and Pareto charts, process flowcharts and radar charts were created to visualise the changes before and after QCC implementation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTarget Achievement Rate\u003c/b\u003e = (appropriateness rate of PPI injection use after improvement - appropriateness rate of PPI injection use before improvement)/(target appropriateness rate of PPI injection use - appropriateness rate of PPI injection use before improvement) *100%\u003c/p\u003e \u003cp\u003e \u003cb\u003eImprovement Rate\u003c/b\u003e = (appropriateness rate of PPI injection use after improvement - appropriateness rate of PPI injection use before improvement)/(appropriateness rate of PPI injection use before improvement) *100%\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by Ningbo Natural Science Foundation (Grant No. 2024J363)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the first author, Ming Zhang, upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMeng, X.\u003cem\u003e et al.\u003c/em\u003e Efficacy and safety of proton pump inhibitors and H2 receptor antagonists in the initial non‑eradication treatment of duodenal ulcer: A network meta‑analysis. \u003cem\u003eExperimental and therapeutic medicine\u003c/em\u003e \u003cstrong\u003e25\u003c/strong\u003e, 273 (2023). https://doi.org/10.3892/etm.2023.11971\u003c/li\u003e\n\u003cli\u003eSchnoll-Sussman, F., Niec, R. \u0026amp; Katz, P. O. Proton Pump Inhibitors: The Good, Bad, and Ugly. \u003cem\u003eGastrointestinal endoscopy clinics of North America\u003c/em\u003e \u003cstrong\u003e30\u003c/strong\u003e, 239-251 (2020). https://doi.org/10.1016/j.giec.2019.12.005\u003c/li\u003e\n\u003cli\u003evan Vliet, E. P.\u003cem\u003e et al.\u003c/em\u003e Inappropriate prescription of proton pump inhibitors on two pulmonary medicine wards. \u003cem\u003eEuropean journal of gastroenterology \u0026amp; hepatology\u003c/em\u003e \u003cstrong\u003e20\u003c/strong\u003e, 608-612 (2008). https://doi.org/10.1097/MEG.0b013e3282f52f95\u003c/li\u003e\n\u003cli\u003eSavarino, V., Dulbecco, P., de Bortoli, N., Ottonello, A. \u0026amp; Savarino, E. The appropriate use of proton pump inhibitors (PPIs): Need for a reappraisal. \u003cem\u003eEuropean journal of internal medicine\u003c/em\u003e \u003cstrong\u003e37\u003c/strong\u003e, 19-24 (2017). https://doi.org/10.1016/j.ejim.2016.10.007\u003c/li\u003e\n\u003cli\u003eSavarino, V., Dulbecco, P. \u0026amp; Savarino, E. Are proton pump inhibitors really so dangerous? \u003cem\u003eDigestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver\u003c/em\u003e \u003cstrong\u003e48\u003c/strong\u003e, 851-859 (2016). https://doi.org/10.1016/j.dld.2016.05.018\u003c/li\u003e\n\u003cli\u003eEusebi, L. H.\u003cem\u003e et al.\u003c/em\u003e Proton pump inhibitors: Risks of long-term use. \u003cem\u003eJournal of gastroenterology and hepatology\u003c/em\u003e \u003cstrong\u003e32\u003c/strong\u003e, 1295-1302 (2017). https://doi.org/10.1111/jgh.13737\u003c/li\u003e\n\u003cli\u003eMatsuda, K. [Definition of the QC (quality control) circle activities]. \u003cem\u003eKango tenbo. The Japanese journal of nursing science\u003c/em\u003e \u003cstrong\u003e8\u003c/strong\u003e, 51-57 (1983). \u003c/li\u003e\n\u003cli\u003eKrause, G., Benzler, J., Reiprich, G. \u0026amp; G\u0026ouml;rgen, R. Improvement of a national public health surveillance system through use of a quality circle. \u003cem\u003eEuro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 246-248 (2006). \u003c/li\u003e\n\u003cli\u003eLi, J.\u003cem\u003e et al.\u003c/em\u003e Pharmacist-led quality control circle in sustained reduction of carbapenem-resistance at a Chinese tertiary teaching hospital. \u003cem\u003eAnnals of palliative medicine\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e, 11558-11565 (2021). https://doi.org/10.21037/apm-21-2644\u003c/li\u003e\n\u003cli\u003eStrand, D. S., Kim, D. \u0026amp; Peura, D. A. 25 Years of Proton Pump Inhibitors: A Comprehensive Review. \u003cem\u003eGut and liver\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 27-37 (2017). https://doi.org/10.5009/gnl15502\u003c/li\u003e\n\u003cli\u003eInadomi, J. M. \u0026amp; Fendrick, A. M. PPI use in the OTC era: who to treat, with what, and for how long? \u003cem\u003eClinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association\u003c/em\u003e \u003cstrong\u003e3\u003c/strong\u003e, 208-215 (2005). https://doi.org/10.1016/s1542-3565(04)00717-7\u003c/li\u003e\n\u003cli\u003eYadlapati, R. \u0026amp; Kahrilas, P. J. When is proton pump inhibitor use appropriate? \u003cem\u003eBMC medicine\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, 36 (2017). https://doi.org/10.1186/s12916-017-0804-x\u003c/li\u003e\n\u003cli\u003eDharmarajan, T. S. The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing. \u003cem\u003eJournal of the American Medical Directors Association\u003c/em\u003e \u003cstrong\u003e22\u003c/strong\u003e, 15-22 (2021). https://doi.org/10.1016/j.jamda.2020.09.046\u003c/li\u003e\n\u003cli\u003eForgacs, I. \u0026amp; Loganayagam, A. Overprescribing proton pump inhibitors. \u003cem\u003eBMJ (Clinical research ed.)\u003c/em\u003e \u003cstrong\u003e336\u003c/strong\u003e, 2-3 (2008). https://doi.org/10.1136/bmj.39406.449456.BE\u003c/li\u003e\n\u003cli\u003eLin, L.\u003cem\u003e et al.\u003c/em\u003e Sustained accuracy improvement in intraocular lens power calculation with the application of quality control circle. \u003cem\u003eScientific reports\u003c/em\u003e \u003cstrong\u003e7\u003c/strong\u003e, 14852 (2017). https://doi.org/10.1038/s41598-017-14171-9\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Quality Control Circles (QCC), Proton Pump Inhibitors (PPIs), Artificial Intelligence (AI), Rational Drug Use","lastPublishedDoi":"10.21203/rs.3.rs-6012541/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6012541/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eProton pump inhibitors (PPIs) are a class of drugs that inhibit gastric acid secretion, and their overuse in clinical practice are relativity common. We developed a quality control circles (QCC) assisted by artificial intelligence (AI) and led by clinical pharmacists to improve the rational use of (PPIs) among hospitalised patients at our hospital. A QCC team was established to follow QCC procedures. The root causes of inappropriate use were identified using AI-assisted brainstorming, and corresponding strategies were developed. The rational use rates of injectable PPIs before and after QCC implementation were calculated and compared. After QCC implementation, the rational use rate of injectable PPIs among hospitalised patients in our hospital increased from 66.51\u0026ndash;93.43%, with a goal achievement rate of 126.92% and a progression rate of 40.47%. The increase in the rational use rate of PPIs was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, team cohesion, responsibility and proficiency in QCC techniques improved after QCC implementation. Furthermore, the standardised process for using injectable PPIs became more regulated after QCC implementation. AI-assisted, clinical pharmacist-led QCCs can serve as an efficient management tool for improving the rational use of injectable PPIs in hospitalised patients, thereby advancing the work of rational drug use in clinics.\u003c/p\u003e","manuscriptTitle":"Artificial Intelligence-Assisted Quality Control Circles Led by Clinical Pharmacists to Improve the Rational Use of Injectable Proton Pump Inhibitors in Hospitalised Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-18 13:45:34","doi":"10.21203/rs.3.rs-6012541/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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