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Improving the Pre-Empted Medication Error Reporting System, St. Charles Hospital, Port Jefferson, NY

by LeDoux, Kathleen

Abstract: Beginning in 2004-2005, 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. Determining that certain categories in the clinical interventions performed by pharmacy and the MAR (medication administration record) communications generated by nursing could appropriately be recognized as pre-empted medication errors, the team launched a project to: 1) provide a process to ensure the correctness of the MAR on a daily basis, 2) accurately capture clinical interventions performed by the pharmacy staff, and 3) simplify the process to communicate MAR corrections from the nursing staff to the pharmacist.

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