This session describes how to develop and use proactive approaches to decrease medication-related harm to patients. Gap analysis, mistake proofing, and Six Sigma will be presented as methods for identifying and addressing root causes of error. Two hospital’s experiences will be described—one using a fully electronic medication administration record (MAR) without computerized prescriber order entry (CPOE), and the other using CPOE and a computer-generated paper MAR.

After this presentation you will be able to:

• Describe the use of gap analysis as a means of proactive adverse drug event risk assessment.
• Discuss approaches for analyzing and using data to develop solutions for medication error.
• Identify how these methods can be used to implement the 2008 Anticoagulation National Patient Safety Goal.
• Compare and contrast opportunities for improvement across the different technology environments presented.