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Improvement Report: Reducing Risk in the Medication Delivery Process with Just-In-Time Delivery
Medical Center of Ocean County (Brick, New Jersey, USA) used Failure Modes and Effects Analysis (FMEA) to identify changes to our medication delivery process and were able to reduce the Risk Priority Number for delivery by 54 percent in less than one year.
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Righteous Anger: How the Family of a Medical-Error Victim Is Working to Fix the System
Eighteen-month-old Josie King died from medical errors at The Johns Hopkins Hospital (USA); now her family and the hospital are working together to make sure nothing like that ever happens again.
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Creating a Culture of Safety
People make errors all the time — not because they’re incompetent or uncaring or careless, but rather because of the complicated systems they work in, which really make it difficult not to make mistakes. Because there are so many ways to go astray, it is not appropriate for people to be punished when they make mistakes, and yet that’s exactly what we’ve always done in the past. Rather, we should look upon mistakes as evidence, clues if you will, of a faulty system, and create an environment where people feel comfortable about reporting and discussing them. That kind of a non-punitive environment is essential if we want to get people to do something about preventing mistakes.
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Improvement Report: Reducing ADEs Through Medication Reconciliation
By testing and implementing procedures to reconcile medications, our team at Luther Midelfort (Eau Claire, Wisconsin, USA) was able to decrease discrepancies on medication orders (potential adverse drug events) by 75 percent, which also reduced actual adverse drug events.
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Improvement Report: Reducing Harm from Oversedation
At Miami Valley Hospital (Dayton, Ohio, USA) we reduced harm from narcotic and sedative medications by 50 percent through focusing on the incidence of oversedation. We tracked the percent of patients receiving narcotics or sedatives who had an ADE related to oversedation and also monitored the use of drugs that counteract oversedation.
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Improvement Report: Reducing ADEs per 1,000 Doses
At OSF St. Joseph Medical Center (Bloomington, Illinois, USA), we have reduced the number of ADEs per 1,000 doses by more than 50 percent, primarily by implementing processes to reconcile medications, but also by improving our dispensing process, decreasing harm from anticoagulants, and developing a culture of safety.
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Improvement Report: Using FMEA to Improve Medication Dispensing
Using Failure Modes Effects Analysis (FMEA), our team at Miami Valley Hospital (Dayton, Ohio, USA) evaluated our medication dispensing process on one of our patient care units and made changes to the process that resulted in a 58 percent decrease in the Risk Priority Number.
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