Reducing patient risk from prescription instruction errors—a six sigma approach.

Audiovisual Presentation

Reducing patient risk from prescription instruction errors—a six sigma approach.

June 18, 2008

O'Dell ML; Andell JL; American Society for Quality; ASQ; Creative Healthcare USA.

View more articles from the same authors.

This Web presentation describes how one hospital's new prescription instructions caused errors and demonstrates how the six sigma approach allowed them to make the process safer.

Available at

Related Resources From the Same Author(s)

Ferrari's Formula One handovers and handovers from surgery to intensive care.

September 10, 2008

Man falls off surgical table; St. Joseph's Hospital sued.

August 4, 2010

ISMP medication error report analysis.

December 3, 2008

Serious Safety Events: Getting to Zero. Second Edition.

October 17, 2012

Medical Errors and Patient Safety: A Curriculum Guide for Teaching Medical Students and Family Practice Residents.

March 6, 2005

Classifying laboratory incident reports to identify problems that jeopardize patient safety.

September 7, 2005

Nurses' role in detecting deterioration in ward patients: systematic literature review.

September 30, 2009

Pediatric safety incidents from an intensive care reporting system.

May 27, 2009

Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014.

March 14, 2018

October 3, 2018

Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits.

May 11, 2016

January 11, 2017

Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA.

September 21, 2022

Environmental Cleaning for the Prevention of Healthcare-Associated Infections (HAIs).

September 16, 2015

Disclosure of unanticipated events: creating an effective patient communication policy (part 2 of 3).

March 6, 2005

Improving Education—A Key to Better Diagnostic Outcomes.

March 30, 2022

Implicit racial bias, health care provider attitudes, and perceptions of health care quality among African American college students in Georgia, USA.

January 18, 2023

Disclosure: what works now and what can work even better (part 3 of 3).

March 6, 2005

Patient Safety Risk Management Playbook.

February 10, 2016

Root Cause Analysis Playbook.

February 17, 2016

2015 Patient Safety Core Topics and Tips.

March 27, 2013

Risk Management Pearls for Medication Safety: Part I and Part II.

February 19, 2014

The growing role of the Patient Safety Officer: implications for risk managers.

March 6, 2005

Disclosure of unanticipated events: the next step in better communication with patients (part 1 of 3).

March 27, 2005

Strategies and tips for maximizing failure mode and effect analysis in your organization.

March 27, 2005

Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis.

August 19, 2020

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition.

June 1, 2005

Risk Management Pearls on Disclosure of Adverse Events.

July 26, 2006

Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.

April 13, 2019

Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000.

March 27, 2005

Metric units and the preferred dosing of orally administered liquid medications.

April 15, 2015

Demanding Medical Excellence. Doctors and Accountability in the Information Age.

March 6, 2005

The misery of a doctor's first days.

October 14, 2015

The Patients' View: 2004 ISQSH National Survey.

January 4, 2006

White patients’ physical responses to healthcare treatments are influenced by provider race and gender.

July 20, 2022

Fourth Cause Campaign.

April 23, 2021

ISMP medication error report analysis.

December 9, 2009

ISMP medication error report analysis.

June 6, 2007

ISMP medication error report analysis.

September 26, 2007

ISMP medication error report analysis.

January 9, 2008

ISMP medication error report analysis.

February 13, 2008

AHRQ 2008 Annual Conference.

January 6, 2010

AHRQ 2009 Annual Conference.

January 6, 2010

AHRQ 2010 Annual Conference.

December 1, 2010

Medical Liability Reform & Patient Safety Initiative.

June 23, 2010

Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R18).

April 25, 2018

PSO Privacy Protection Center.

November 5, 2008

Bar-Coded Medication Administration (BCMA).

September 24, 2008

AHRQ WebM&M: Morbidity & Mortality Rounds on the Web.

March 6, 2005

Researching Implementation and Change while Improving Quality (R18).

April 23, 2008

HCUPnet.

March 6, 2005

Quick Tips—When Getting A Prescription.

March 6, 2005

Twenty Tips to Help Prevent Medical Errors in Children.

March 6, 2005

20 Tips to Help Prevent Medical Errors.

March 6, 2005

Ways You Can Help Your Family Prevent Medical Errors!

March 6, 2005

Patient Safety Challenge Grants.

March 6, 2005

Improving patient safety with team coordination: challenges and strategies of implementation.

August 9, 2006

Radiation Oncology Incident Learning System.

January 14, 2015

Questions to ask about radiation safety.

April 7, 2010

Thirty Safe Practices for Better Health Care.

April 15, 2005

Inappropriate prescribing of opioids for patients undergoing surgery.

December 21, 2022

Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic.

July 28, 2021

Fall Prevention in Hospitals Training Program.

October 4, 2017

Health Care Facility Design Safety Risk Assessment Toolkit.

September 27, 2017

Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development.

November 9, 2022

Workplace Safety Supplemental Item Set for Hospital SOPS.

November 17, 2021

Healthcare 411: medication safety toolkit.

March 18, 2009

Surveys on Patient Safety Culture.

April 27, 2023

Hospital Survey on Patient Safety Culture 2.0.

June 1, 2022

Guide to Healthcare Quality: How to Know It When You See It.

September 21, 2005

ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications.

March 9, 2011

Standardize 4 Safety.

May 25, 2016

ASH Clinical Practice Guidelines on Venous Thromboembolism.

January 9, 2019

Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital.

November 26, 2014

Enteral Nutrition Safety Toolkit.

February 18, 2009

Anesthesia Awareness Registry.

April 11, 2007

Patient Safety Resource Center.

August 24, 2005

Joint Statement on Multiple Patients Per Ventilator.

April 22, 2020

Pain Alleviation Toolkit.

April 8, 2020

Eliminating Dangerous Abbreviations, Acronyms and Symbols.

July 6, 2005

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

Medical research and the Institutional Review Board: the librarian's role in human subject testing.

October 26, 2005

Nursing Home Antimicrobial Stewardship Guide.

November 9, 2016

Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections.

July 7, 2021

SOPS Health Information Technology Patient Safety Supplemental Item Set for the Hospital Survey.

March 28, 2018

AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.

June 13, 2018

AHRQ Communication and Optimal Resolution (CANDOR) Toolkit.

May 25, 2016

Ambulatory Surgery Center Survey on Patient Safety Culture.

May 29, 2023

Toolkit for Reducing CAUTI in Hospitals.

December 9, 2015

AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.

February 6, 2019

Improving Your Office Testing Process: A Step by Step Guide for Rapid-Cycle Patient Safety and Quality Improvement.

September 25, 2013

TeamSTEPPS 2.0 for Long-Term Care.

November 28, 2012

Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems.

October 31, 2012

Guide to Patient and Family Engagement in Hospital Quality and Safety.

July 24, 2013

Community Pharmacy Survey on Patient Safety Culture.

October 24, 2022

CUSP Toolkit.

September 26, 2019

The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety.

May 30, 2012

Health Literacy Tools for Providers of Medication Therapy Management.

August 16, 2017

Toolkit to Promote Safe Surgery.

January 17, 2018

Pressure Injury Prevention in Hospitals Training Program.

October 18, 2017

Related Resources

Ambulatory CUSP (Comprehensive Unit Based Safety Program) Training.

May 9, 2024 - May 10, 2024

CUSP Implementation Training.

July 16, 2024 - July 16, 2024

Redesigning Event Review with RCA2.

September 10, 2024 - September 17, 2024

National Action Alliance to Advance Patient and Workforce Safety Webinar Series.

September 26, 2023 - September 26, 2023

Patient Safety Executive Development Program.

September 10, 2024 - October 22, 2024

ISMP Medication Safety Intensive.

April 12, 2024 - April 19, 2024

Certified Professional in Patient Safety Review Course.

June 5, 2024 - June 6, 2024

Optimizing Geriatric Safety and Well-being: Implementing Best Practices and Strategies.

March 12, 2024 - March 12, 2024

TeamSTEPPS Master Training Course.

June 11, 2024 - June 13, 2024

The Sunday story: when hospitals don't say sorry.

January 31, 2024

Unequal Treatment Revisited: A Workshop Series.

September 26, 2023 - September 27, 2023

Annual Communication, Apology, and Resolution (CARe) Forum.

August 10, 2023

SOPS Ambulatory Surgery Center Survey: What You Need to Know.

April 27, 2023 - April 27, 2023

Just a Cup of Tea – an Introduction to the SEIPS Framework.

May 24, 2023

World Patient Safety, Science & Technology Summit.

June 1, 2023 - June 2, 2023

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.

February 15, 2023

Emerging Topics in Quality Improvement.

February 14, 2023 - February 14, 2023

Driving Learning and Improvement After RCA2 Event Reviews.

January 11, 2023

Opportunities to Improve Patient Safety, Advancing U.S. Innovation, and Innovation Hubs.

October 5, 2022

Creating a Communication Coaching Structure and Support for your CRP Program.

September 12, 2022 - September 12, 2022

Addressing the Loss of Trust in Safety Culture.

September 7, 2022

Medication Safety Certificate Program.

August 24, 2022

A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network.

August 17, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Engaging Physicians in Teamwork Training for Quality and Safety - Or Why Don’t Your Physicians Get Engaged?

June 8, 2022 - June 8, 2022

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

May 6, 2022 - May 6, 2022

Using human factors and ergonomics principles to prevent inpatient falls.

April 20, 2022

Diversion is a Threat to Patient Safety: Adopting Best Practices.

April 6, 2022 - April 6, 2022

New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals.

December 16, 2021 - December 16, 2021

Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.

November 10, 2021

See More About The Topic

Hospitals

Quality and Safety Professionals

Six Sigma

Reducing patient risk from prescription instruction errors—a six sigma approach.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Reducing patient risk from prescription instruction errors—a six sigma approach.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site