Abstract
Purpose
To measure the impact of an individual pharmacist performance report (IPPR) program on pharmacist-related medication order entry errors (MOEEs) at an academic medical center.
Methods
The number and type of pharmacist-related MOEEs were collected at 2 different times: immediately following implementation of an electronic medical record (baseline) and following completion of the IPPR program. Three different collection methods were utilized to identify and categorize pharmacist-related MOEEs: 1) Patient Safety Net (PSN) incident reporting system, 2) manual event reporting, and 3) a nursing to pharmacy electronic messaging system. The IPPR program consisted of mandatory educational sessions for pharmacist staff. The program content focused on strategies to reduce pharmacist-related MOEEs identified in the baseline data collection period as well as an individualized report generated for each pharmacist having caused an MOEE that showed their performance compared to the department's performance.
Results
The percentage of event reports containing a pharmacist-related MOEE decreased from baseline to post IPPR program (13.7% and 6.3%, respectively; P < .001). In addition, the total number of pharmacist-related MOEEs was halved after the IPPR program (321 vs 148; P < .001). Significant reductions were noted in the following MOEE categories: duplicate orders, missed orders, wrong frequency, wrong dose, and other. Nonsignificant reductions were noted in errors related to no order and wrong drug.
Conclusion
Based on the observations and results of this study, it is proposed that individualized performance feedback can be a successful method to improve MOEE performance by pharmacists.
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