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Missing Doses: A Performance Improvement Project

Ross, Johnanne (2020) Missing Doses: A Performance Improvement Project. Master Essay, University of Pittsburgh.

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Doses that are not available for administration to a patient at the time needed are known as missing doses. Missing doses affect the quality of patient care, staff satisfaction, and cause waste in manpower and in medications. This project was undertaken at a 363-bed acute care hospital in Pittsburgh, PA. The purpose of the project was to evaluate the extent and causes of missing doses and address processes to decrease missing doses. The project adds value to pharmacists and nurses due to the nature of their professional responsibilities. This project is also relevant to public health because the medications are not available when needed for patient care. Nursing staff from four inpatient care units and the Pharmacy staff participated. The project leader sent pre- and post-surveys to the Nursing and Pharmacy staff. After the pre-survey, missing dose documentation was collected and analyzed by the project leader for a period of two weeks. Subsequently, data were reviewed by the project team (nurses and pharmacists). Process changes were designed and implemented. The second phase of the study began with a second survey. Following that survey, missing doses were collected and analyzed a second time. As in the first phase, data were evaluated by the project team. During both phases, the survey and missing dose data were congruent in many of the issues noted. As a result of this project, there were noted improvements in 1) dispensing automation issues; 2) transfer issues; 3) the ability to locate medications on the patient care unit; 4) pharmacy turnaround time; and 5) nursing requests prior to Pharmacy’s ability to dispense and deliver. There are still opportunities for improvement. Such opportunities include the need for refined processes for the use of the pneumatic tube system, patient medication transfers, and the ability to locate medications on the patient care unit. Future endeavors of this project will include additional patient care areas. Also, a separate project will differentiate small and large volume admixed parenteral medications from ready-to-use products and non-sterile products. This project highlighted the complexity of the dispensing and administration of medications, both of which, are a part of the medication use process.


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Item Type: Other Thesis, Dissertation, or Long Paper (Master Essay)
Status: Unpublished
CreatorsEmailPitt UsernameORCID
Ross, Johnannerossjx2@verizon.netJOR910000-0001-9977-0803
ContributionContributors NameEmailPitt UsernameORCID
Committee ChairFriede, Samuelfriede@pitt.eduUNSPECIFIEDUNSPECIFIED
Date: 25 March 2020
Date Type: Completion
Number of Pages: 52
Institution: University of Pittsburgh
Schools and Programs: School of Public Health > Health Services Administration
Degree: MHA - Master of Health Administration
Thesis Type: Master Essay
Refereed: Yes
Date Deposited: 25 Aug 2020 19:39
Last Modified: 25 Aug 2020 19:39


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