In the current atmosphere of closer scrutiny of healthcare practices and procedures, front-line managers and health care providers must investigate potential problems in their work environment, whether at the behest of upper management, in order to meet Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards, or through their own sense that “weÆre doing something wrong.” For the investigator with limited previous experience in evaluation or research, the prospect of undertaking this kind of investigation can appear daunting, to say the least. Quality Improvement Projects in Health Care was written just for this individual. Author Eleanor Gilpatrick, a seasoned investigator and professor of health services administration, provides a review of the basic terminology and guidelines for carrying out “nuts-and-bolts” quality improvement research. She then demonstrates how such a research project can be implemented through 14 case studies involving actual health care situations. Altogether, the cases speak to a broad array of issues and potential pitfalls for the unwary investigatorŭand they show that progress can be made in even the most difficult circumstances. Quality Improvement Projects in Health Care will be of interest to students and professionals in health sciences administration, nursing, allied health, and public health.

Errors in Filling Prescriptions in a Hospital Pharmacy1

Errors in Filling Prescriptions in a Hospital Pharmacy1
Case 8: Errors in filling prescriptions in a hospital pharmacy

Sometimes problems or opportunities for improvement appear at the interface between departments. In this case, complaints from nursing stations about medications delivered by the pharmacy pinpointed an area needing attention.

Proving the Problem

The Problem and the Client

Hope was an office manager in the pharmacy of a voluntary hospital. The pharmacy management was concerned about reports from nursing stations that patients’ medications arrived with errors; when Hope expressed an interest in quality assessment, she was asked to find the causes of the problem and come up with some solutions. As the office manager, Hope was somewhat removed from actual pharmacy operations, but she was interested in quality improvement. The pharmacy ...

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