Team # 964 -- Pharmacy Quality Improvement
Student Affairs

October 2010


To insure that 100% of prescriptions filled go to the correct patient.

During July/Aug 2010, 24,830 prescriptions were filled by the UHS pharmacy; although the error rate is very small (0.0002%), there is a potential for a negative outcome. The goal is that 100% of prescriptions filled must go to the correct patient.

Team Membership

  • Jim Gill, Leader
  • Jonathan Borowski, Member
  • Patricia Grieb, Member
  • Doris Guanowsky, Member

Results Achieved to Date

  • ExpectedResults:

    The pharmacy conducted a root cause analysis to identify factors such as interruptions, work environment, assistive technology, and staffing levels which may contribute to loss of concentration or error. As a result, some work flow processes were redesigned, and an additional pharmacist was added.

    The pharmacy director will continue to track and analyze error data and make corrective actions to continue to improve the pharmacy services.




Office of Planning and Institutional Assessment
The Pennsylvania State University
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