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All Haj Har Sam Gnrs 586 Qi Presentation
All Haj Har Sam Gnrs 586 Qi Presentation
Medication Error
Kanchana Allan, Alia Hajou,
Jessica Johnson & Saranya Sampath
Background
Materials Machines
Root Cause Analysis Continued
A lack of safety checks preceded the
administration of the incorrect medication,
leading to the death of an infant
Actions to Prevent Future Occurrence
● Hospital will purchase products from different manufacturers
○ to eliminate look-alike errors
● Review how look-alike, sound-alike drugs should be stored
○ highlight and separate drugs that could potentially be confused
○ pharmacy should ensure that the pyxis is functioning appropriately
● Improve systems of communication between nurses and prescribers
○ all orders should include the indication for the drug
● Organization should provide safety training for staff
○ the six rights of medication administration should always be done to
eliminate medication errors
○ in an emergency situation they must be done out loud with another
staff member
Outcome Measures
Numerator: Number of medication errors
• One month after implementing a new storage system for look-alike/ sound-
alike drugs, the number of medical errors on the unit will be reduced by
100 percent.
Root Cause Outcome Measure
Measures the impact the action will have on the root cause
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