This study examined the effect of a custom alert intended to reduce medication-timing errors associated with introduction of computerized provider order entry, which can lead to too-frequent or missed doses of medications. Using a rigorous interrupted time-series design, researchers found fewer medication-timing errors after implementation of this alert. This work demonstrates how custom alerts developed by clinicians can harness the electronic health record to improve safety.

This study highlights the use of Lean methodologies to facilitate implementation of barcode medication administration (BCMA) for hospitalized patients at Virginia Mason Medical Center. The introduction of BCMA led to significantly fewer medication errors. The concepts presented may be helpful for organizations employing new health technologies.

Errors during administration are one of the most common types of medication errors, with one study showing that they occur in nearly 25% of doses in hospitalized patients. Lean methodology, derived from the Toyota Production System, is increasingly being used in health care as a way to design safer and more efficient systems of care. This study reports on the application of Lean approaches to improving medication administration safety. A redesigned medication administration system that incorporated human factors engineering techniques to minimize interruptions, implement barcode medication administration, and standardize nursing workflows resulted in a significant reduction in administration error rates. The study provides a useful example of how quality improvement techniques originally developed in other industries can be successfully applied in health care.

Use of Lean methodology helped restructure the surgical instrument sterilization and preparation process according to human factors engineering principles, resulting in a sustained decrease in the instrument processing error rate.