Dose 10 Omission 44 Wrong Dose 8 Wrong Time 7 79 Dispensing Process Baseline 1Q 2Q 3Q 4Q Measure Unit 2016 Goal 2017 2017 2017 2017 1. Controlled Substance Loss All 0% 0.19% Data: Daily Pyxis-CII Safe Target: 0% Compare Report. Actual: 0% 2. Controlled Substance Loss Rx 0 Data: Monthly CII Safe 0 Target: 0 0 Vendor Receipt Report. Actual: 0 0 3. Controlled Substance Loss All Data: Monthly Pyxis 0/mo Target: 0 0 Controlled Drug Actual: 0 0 Discrepancies. (0/mo) 4. Medication Management Rx Monitoring: Measures of 10/year Target: 0 0 drug reactions, adverse drug Actual: 0 10 events, and other management data. 5. Medication Management Rx 136/ 100% Monitoring: Resource quarter Target: 100% Documentation Reports of Actual: 167 Clinical Interventions. 6. Psychiatric Emergency All 100% 100% Process: Monthly audit of all Target: 100% psych emergency measures Actual: 100% against 8 criteria. 7. Operational Audit: Rx 100% 100% Target: 100% Actual: 100%
Dose 10 Omission 44 Wrong Dose 8 Wrong Time 7 79 Dispensing Process Measure Unit Baseline 2016 Goal 1Q 2017 2Q 2017 3Q 2017 4Q 2017 1. Controlled Substance Loss Data: Daily Pyxis-CII Safe Compare Report. All 0.19% 0% Target: Actual: 0% 0% 2. Controlled Substance Loss Data: Monthly CII Safe Vendor Receipt Report. Rx 0 0 Target: 0 Actual: 0 0 0 3. Controlled Substance Loss Data: Monthly Pyxis Controlled Drug Discrepancies. All 0/mo Target: 0 Actual: 0 0 0 (0/mo) 4. Medication Management Monitoring: Measures of drug reactions, adverse drug events, and other management data. Rx 10/year Target: 0 Actual: 0 0 10 5. Medication Management Monitoring: Resource Documentation Reports of Clinical Interventions. Rx 136/ quarter 100% Target: Actual: 100% 167 6. Psychiatric Emergency Process: Monthly audit of all psych emergency measures against 8 criteria. All 100% 100% Target: Actual: 100% 100% 7. Operational Audit: Rx 100% 100% Target: Actual: 100% 100%
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