root cause analysis

START

CPOE- COMPUTERIZED

PHYSICIAN ORDER ENTRY

PHARMACY TECH CHOOSES MED OFF THE SHELF

STOCKS UNIT DOSE CART

FOR PATIENT

NURSE CHOOSES MED FROM

UNIT DOSE CART

NURSE SCANS BARCODE

SCANNER SHOWS MATCH

MED ADMINISTERED USING 7 RIGHTS

ELECTRONIC DOCUMENTATION

VIA BARCODE

NURSE DOCUMENTS

ANY REACTIONS

NURSE MANUALLY ENTERS INTERNAL

ENTRY NUMBER

MATCH?

NURSE CALLS PHARMACY

SITUATION CLARIFIED?

NURSE CALLS SUPERVISOR

FOR GUIDANCE

END

PROCESS FLOW CHART: MEDICATION ADMINISTRATION

DOWNTOWN MEDICAL

YES NO

YES NO

YES