American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists
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Am J Health Syst Pharm · Dec 2000
Re-engineering the medication error-reporting process: removing the blame and improving the system.
A hospital's change from a traditional, multitiered incident-reporting system for medication errors to a standardized, nonpunitive medication-use variance process is described. After weaknesses were identified in the hospital's system for reporting and evaluating medication errors, a multidisciplinary task force was formed to redesign the hospital's medication error-reporting system. Its guiding principles were as follows: anonymity and freedom from punitive action are essential for increasing the number of reports, rating medication errors facilitates identification of areas for system improvement, potential errors provide valuable insight into the system's vulnerabilities, and timely review of reports enables rapid systematic correction. ⋯ In the first six months following hospitalwide implementation, the number of events captured increased more than fivefold; it continues to increase. The resulting database serves as a trigger for quality improvement efforts and a measure of their effectiveness. The redesign of the medication error-reporting process served as the impetus for a change in the organizational culture surrounding medication errors.
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Am J Health Syst Pharm · Dec 2000
Improving the quality of the order-writing process for inpatient orders and outpatient prescriptions.
Because many preventable medication errors occur at the ordering stage, a program for improving the quality of writing inpatient orders and outpatient prescriptions at one institution was developed. To determine whether potential problems existed in the order-writing process for inpatients, all physician orders for a seven-day period in 1997 were reviewed (n = 3740). More than 10% of all orders had illegible handwriting or were written with a felt-tip pen, which makes NCR copies difficult to read. ⋯ Follow-up reviews of outpatient prescriptions indicate improvements in handwriting and completeness, but continuing educational efforts are needed. The quality of order writing for inpatients and outpatients continues to be monitored on a regular basis. Ongoing educational programs, follow-up reminders, and feedback to physicians have greatly improved the prescription-writing habits of physicians.