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PSNet: Patient Safety Network
Newspaper/Magazine Article

Near-miss event analysis enhances the barcode medication administration process.

Magee MC; Miller K; Patzek D; Madera C; Michalek C; Shetterly M.

Near misses provide unique opportunities to identify and learn from safety hazards. Describing how one organization utilized data on near misses involving barcode medication administration over a 12-year period to reduce barcode-workflow events, this report outlines practices and strategies that contributed to success such as promoting event reporting and applying root cause analysis.