Near-miss event analysis enhances the barcode medication administration process
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Magee, Mary C., author Miller, Krista, author Patzek, Dorothy, author Madera, Candy, author Michalek, Christina, author Shetterly, Megan, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, December 2017
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Automatic Data Processing Medication Errors -- prevention & control Patient safety Benchmarking Medication Errors -- statistics & numerical data Medication Errors -- trends Medication Therapy Management Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- Near-miss event reporting and analysis is an essential part of a robust patient safety program. Pennsylvania has seen an increase of more than 2,700% in reports of near-miss barcode medication administration (BCMA) events over twelve years, from January 2005 through December 2016. During the same period, events that reached the patient and caused harm (Serious Events) accounted for only 0.5% of reported BCMA-related events. Reporting, but more importantly, the analysis of near-miss events can lead to improvements in processes and reduce the potential for patient harm. Through a case study, the Pennsylvania Patient Safety Authority shares the story of how Blue Mountain Health System reduced its barcode-workflow events by 53% between 2014 and 2016. Through a collaborative effort with the Authority's analysts and patient safety liaison, the health system used near-miss event review and analysis to improve its BCMA process. The Authority shares best practice strategies for BCMA use in the context of near-miss event analysis.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Extent:
- 1 online resource (1 PDF file (17 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101718712 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101718712