title: One hospital's journey toward reducing medication errors.
abstract: BACKGROUND
  The Valley Hospital, a 451-bed acute care facility in Ridgewood, New Jersey, has made substantial progress in the reduction of medication administration errors.
  
  
  METHODS
  Reduction in medication administration errors were accomplished through (1) becoming intimately familiar with the errors, including where, when, why, and how they were occurring; (2) establishing a nonpunitive environment and encouraging reporting of errors, including near-miss errors; (3) trending error report data to identify areas of concentrated errors in the medication use process; (4) simplifying and standardizing process steps; and (5) selecting the right technology to address error-prone steps in the hospital's systems.
  
  
  RESULTS
  The establishment of a nonpunitive environment led to a dramatic increase in the number of nearmiss errors reported, and the information gained proved to be valuable and diagnostic. Establishing an interview process with the caregivers directly involved in occurrences enabled us to gather detailed information about errors. This forum led the way to an early understanding of human factors, system failures, and root cause analysis. Those errors were trended, addressed, and reduced through manual system changes and technological system developments designed to ensure the "five rights" of safe medication administration.
  
  
  CONCLUSIONS
  Keeping on course requires constant and continuous review of medication use processes to ensure that they support instead of unnecessarily limit actual practices.
authors.affiliation: Clinical Systems and Quality Improvement, Valley Hospital, Ridgewood, New Jersey, USA. mmutter@valleyhealth.com
authors.forename: Michael
authors.initials: M
authors.lastname: Mutter
mesh_terms: D006745:Hospital Bed Capacity, 300 to 499; D006753:Hospital Records; D006801:Humans; D007407:Interviews as Topic; D008508:Medication Errors / Q000145:classification / Q000517:prevention & control* / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital / Q000592:standards*; D009515:New Jersey / Q000453:epidemiology; D010564:Personnel, Hospital; D017064:Process Assessment, Health Care; D012308:Risk Management / Q000379:methods*; D017751:Safety Management / Q000379:methods; D018571:Sentinel Surveillance; D012985:Software Design; D013597:Systems Analysis