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GEOFFREY A. RICKRODE, PHARM.D., is Clinical Staff Pharmacist— Adult Critical Care, Department of Pharmacy; MARVA E. WILLIAMS-LOWE, PHARM.D., is Acting Director of Pharmacy, Department of Pharmacy; JANE L. RIPPE, M.S., is Pharmacy Manager of Operations, Department of Pharmacy; and ROBERT H. THERIAULT, JR., M.B.A., is Pharmacy Manager of Business and Finance, Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Address correspondence to Dr. Rickrode at the Department of Pharmacy, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756 (geoffrey.a.rickrode{at}hitchcock.org).

Purpose. The current pharmacy occurrence-reporting system in an institution was reviewed, and an internal procedure that would provide data to improve the medication-use process was developed. Summary. In a rural, 353-bed, tertiary care academic center, the effectiveness of a departmental occurrence-reporting system was determined over a nine-month period to increase occurrence reporting within the pharmacy and allow administrators to identify specific areas for improvement within the medication distribution process. These events were identified according to the number and type of near misses documented by pharmacy staff. The pharmacy staff was asked to complete a survey about the department’s current reporting process and what the staff desired in a new occurrence-reporting system. The staff was also surveyed on which steps of the pharmacy’s medication distribution process could contribute to the most errors. Initially, a paper-based error-reporting form was developed for all steps of the pharmacy distribution process except pharmacist order entry. Once the paper-based error-reporting form was introduced, the pharmacist order-entry phase of the project was begun. During the evaluation period, 203 pharmacy-dispensing errors were reported to the hospital’s error-reporting system. In contrast, 1385 total pharmacy events were documented using the pharmacy’s internal occurrence-reporting system. At least 204 of those reported events involved high-alert medications according to the institution’s high-alert medications policy. Conclusion. A pharmacy internal occurrence-reporting system increased staff reporting and identified areas for improvement within the medication distribution process that may not have been recorded by a hospital-based reporting system. Index terms: Dispensing; Drug distribution; Errors, medication; Pharmacy, institutional, hospital; Reports