• Confirmation process
• Don't "borrow" medications
• Lbs versus kgs
• Incompatible medications
• Illegible orders
• Medication orders
• Medication reconciliation
• Patient identification
• Patients who use sleeping agents
• Remember the "5 Rights"
Situation:
SWSA employees offered SWSA leadership feedback, voicing concerns that they don’t know what happens to Unusual Occurrence Reports (UOR) after they are filed.
Background:
Hospital leaders heard employees and examined ways to respond. SWSA is moving along a journey of transparency to staff, patients and our community. Sharing what we learn is one way to get everyone invested and involved.
Assessment:
UOR responses should be available as learning tools to employees. The PSPH Medication Safety Coordinator and SWSA Vice President of Quality have summarized individual UORs in the Close Calls Safety Briefs. The purpose of the brief is to share and spread safety information across the organization.
Recommendation:
Close Calls Safety Briefs are now available as learning tools for staff. Hard copies are being distributed on the units and electronic copies are available on the PSPH Intranet site. Please contact SWSA Quality Vice President Jill Cooper, ext. 34983, or Julie McCoy, Medication Safety Coordinator, ext. 34750, with questions, comments or suggestions.