Case Studies
Complacency as a Root Cause of Medication Errors
A temporary reduction in pharmacy hours at Clifton Springs Hospital and Clinic contributed to medication error rates in 2010 that were the highest in three years. The hospital leadership thought it had 'human-proofed' its process by requiring a double-check for overrides and medication administration record (MAR) transcription and had a pharmacist remotely enter medications into the patient's profile. However, two categories of errors became apparent: overrides from the automated dispensing cabinets and discrepancies between the one or two handwritten MARs a patient may have before the electronic MAR is produced.
A temporary reduction in pharmacy hours at Clifton Springs Hospital and Clinic contributed to medication error rates in 2010 that were the highest in three years. The hospital leadership thought it had 'human-proofed' its process by requiring a double-check for overrides and medication administration record (MAR) transcription and had a pharmacist remotely enter medications into the patient's profile. However, two categories of errors became apparent: overrides from the automated dispensing cabinets and discrepancies between the one or two handwritten MARs a patient may have before the electronic MAR is produced.