11/13/2015 Y OMISSION N N N US 2 1 3 12/4/2015 N EXTRA DOSE N N N US 1 0 4 12/29/2015 N DOSE Y N N LSS 1 0 3 LS: US: LK: UK: Totals: 40 22 9 1 23 25 35 5 Percent 45% 88 Total Errors 25% 10% 1% 26% 28% 40% 6% *Each dose of medication is documented as an individual variance (error) Type of Error # of Extra Dose 15 Errors Omission 40 Dose 11 Wrong Drug 4 Wrong Form 11 Wrong Time 6 Wrong Route 1 JOINT COMMISSION Dispensing Process 1Q Baseline 3Q 4Q 2Q 2016 Measure Unit 2014 Goal 2015 2015 2016 1. Controlled Substance Loss Data: All 0.875% 0% Pyxis-CII Safe Compare Target: 0% 0% 0% 0% Report. Actual: 0% 0% 0% 0% 2. Controlled Substance Loss Data: Rx 0 0 Monthly CII Safe Vendor Receipt Target: 0 0 0 0 Report. Actual: 0 0 0 0 3. Controlled Substance Loss Data: All 0/mo 0 Monthly Pyxis Controlled Drug Target: 0 0 0 0 discrepancies. Actual: 0 0 0 0 (0/ (0/ (0/ (0/ mo) mo) mo) mo) 4. Medication Management Rx 8/year 0 Monitoring: Measures of drug Target: 0 0 0 0 reactions, adverse drug events and Actual: 2 3 0 0 other management data. 5. Medication Management Rx 99/ 100% Monitoring: Resource quarter Target: 100% 100% 100% 100% Actual: 73 56 31 144
11/13/2015 Y OMISSION N N N US 2 1 3 12/4/2015 N EXTRA DOSE N N N US 1 0 4 12/29/2015 N DOSE Y N N LSS 1 0 3 Totals: 40 22 9 1 LS: 23 US: 25 LK: 35 UK: 5 Percent 45% 88 Total Errors 25% 10% 1% 26% 28% 40% 6% *Each dose of medication is documented as an individual variance (error) Type of Error # of Errors Extra Dose 15 Omission 40 Dose 11 Wrong Drug 4 Wrong Form 11 Wrong Time 6 Wrong Route 1 JOINT COMMISSION Dispensing Process Measure Unit Baseline 2014 Goal 3Q 2015 4Q 2015 1Q 2016 2Q 2016 1. Controlled Substance Loss Data: Pyxis-CII Safe Compare Report. All 0.875% 0% Target: Actual: 0% 0% 0% 0% 0% 0% 0% 0% 2. Controlled Substance Loss Data: Monthly CII Safe Vendor Receipt Report. Rx 0 0 Target: Actual: 0 0 0 0 0 0 0 0 3. Controlled Substance Loss Data: Monthly Pyxis Controlled Drug discrepancies. All 0/mo 0 Target: Actual: 0 0 (0/ mo) 0 0 (0/ mo) 0 0 (0/ mo) 0 0 (0/ mo) 4. Medication Management Monitoring: Measures of drug reactions, adverse drug events and other management data. Rx 8/year 0 Target: Actual: 0 2 0 3 0 0 0 0 5. Medication Management Monitoring: Resource Rx 99/ quarter 100% Target: Actual: 100% 73 100% 56 100% 31 100% 144
2016Q2.docx