IHA case studies

Medication Verification Process Across Multiple Disciplines to Prevent Patient Harm from Potential Medication Errors


Patient safety is the number one priority at this facility. After discussing medication errors at a patient safety meeting, it was evident that there were multiple factors contributing to the data presented. Pharmacy, medical/surgical directors, clinical education and IT met and developed a med-verify occurrence form for nursing to complete when a problem occurred with the medication/patient scanner. Analysis of the med-verify occurrences revealed problems with NDC codes, pharmacy using a different process during initial input of medications into the system, 60 percent of occurrences were from two rooms on the med/surg unit and newly installed scanners were not being calibrated before bedside use. Each issue was addressed with corrective action implemented. The most noted improvement occurred when all scanners were re-calibrated and new scanners calibrated before use. After implementation of process improvements, there was a 78 percent reduction in the number of occurrence reports generated after the first six week period and for the following 18-week period. Medication verification, via bar code scanning, demonstrated an improvement in compliance from 55.5 percent to 73.4 percent on the unit.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state.  These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

  • Safe
  • Timely
  • Effective
  • Efficient
  • Equitable
  • Patient-centered

(The Institute of Medicine's six aims for improvement.)

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