Multidisciplinary Redesign of a Medication Error Reporting System

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A multidisciplinary effort to improve the medication-error reporting system is described. Goals included increasing the quantity and improving the quality of data from medication-related occurrences. The processes by which occurrences are tabulated and data are disseminated were reviewed and improved. A primary effort was focused on the development of a new occurrence report form. A new form was developed that captured not only "what happened," but also where in the process the error originated as well as the contributing factors so that steps to prevent reoccurrence could be determined. Extensive educational efforts were made to counter the perceived and real punitive aspects of medication-error documentation. The results have been a sustained 25% increase in the number of documented medication-related occurrences, better data for analyzing trends, and a useful tool for the identification of process-improvement opportunities.

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