Most medication errors occur during physician ordering and medication administration. However, up to 70% of physician ordering errors are intercepted by pharmacists and nurses prior to patient administration. Regrettably, there is no similar human safety net when medications are administered to the patient.
The goal of this project was to reduce the number of medication errors (wrong medication, wrong patient, wrong dose, and extra dose) by fully implementing and maximizing bed-side bar coding into nursing workfl ow.
- Integrated meetings to map out processes and expectations for each step of the medication administration process – including end-user de fined expectations and requirements
- Tested processes as a "dress rehearsal" for each process step and technology usage
- Staff nurses were assigned as champions, super-users and preceptors
- Worked on Medication Database and how it interacts with orders, the eMAR, task lists, and other clinical information in the chart
- Worked closely with IT and Pharmacy to assure that alerting functionality was most appropriate for our patient population
- Worked with Eclipsys/AllscriptsTM to refi ne alerts
- Understanding the limitations of reporting prior to implementing a new system
- Clinical departments needed to take ownership of clinical IT projects
For more information please contact:
Colleen Orlick
Lean Operations/Lean Six Sigma Manager
Colleen.Orlick@ctca-hope.com
