Author: Woodall Sandra C.

Source: Joint Commission Journal on Quality and Patient Safety, Volume 30, Number 8, August 2004 , pp. 442-447(6)

Publisher: Joint Commission Resources

Abstract:

Background: Hendry Regional Medical Center, a 66bed facility, has 8.5 hours of pharmacy staffing daily. Review of two years of medication errors indicated that 34% of all medication errors involved selection of the wrong drug from stock after pharmacy hours.

Process Changes: During 2003 many changes were implemented in the medication management process to enhance medication safety. For example, a limited-access area of the pharmacy was established for night entry by the nursing supervisor. The hospital then implemented services with a newly licensed remote order-entry service. These steps decreased the rate of errors involving wrong drug selection to 15%. Subsequently, a medication error involving selection of the wrong drug at night prompted another look at the process.

Implementing the Video Verification Process: The hospital began using a webcam to create a digital image of the medication selected for removal from the pharmacy stock by the nursing supervisor. This image is transmitted via e-mail. In six months, only one (recent) error resulting from selection of the wrong medication after normal pharmacy hours occurred; the medication selection process simply was not followed.

Discussion: Results of medication error reporting indicated that using Webcam/e-mail image transmission and video verification by a pharmacist further improved patient safety in the medication selection process.

Document Type: Research article

Publication date: 2004-08-01

More about this publication?

• Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
  
  Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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