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HBOK 1-180

Title Improving the Pre-Empted Medication Error Reporting System, St. Charles Hospital, Port Jefferson, NY
Author(s) Kathleen LeDoux
Source Healthcare Division
Topic Performance Improvement

Engaging and Empowering the Workforce

Change Management

Abstract Beginning in 2004-05, a team at St. Charles Hospital, Port Jefferson, NY, began to explore ways to recognize and improve the reporting of pre-empted errors. While traditional reporting via the formal occurrence reporting system was encouraged, other venues for recognition and reporting were considered. First it was determined that certain categories in the clinical interventions performed by pharmacy staff and the medication administration record (MAR) communications generated by nursing staff could appropriately be recognized as pre-empted medication errors. Next, the team launched a project to: provide a process to ensure the correctness of the MAR on a daily basis, accurately capture clinical interventions performed by the pharmacy staff, and  simplify the process to communicate MAR corrections from the nursing staff to the pharmacist.
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Reference Code 1-180

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