San Mateo County Grand Jury
• 2008-2009
Issue | Background | Findings | Conclusions | Recommendations | Responses | Attachments San Mateo Medical Center’s
⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings and Recommendations 5 findings
F1
San Mateo Medical Center (Medical Center) staff is correctly using the Medication Administration Check (MAK) system, and there appears to be no identified abuse or inappropriate use of the system.
Related Recommendations (1)
R1
Improve data used to measure the Medication Administration Check (MAK) system performance by creating bench marks and a baseline to assess the safety and efficiencies when dispensing medication to patients at the Medical Center.
F2
The Medical Center’s goal is to improve the accuracy of patient identification, ensure the effectiveness of communication among caregivers, ensure the safety of administering medications, and encourage the patients’ active involvement in their own health care.
Related Recommendations (1)
R2
Utilize MAK data to make decisions and suggestions for improvement of the current MAK module, and development of future software modules.
F3
Clinicians contributed to the success of the MAK implementation by being involved in the pre-implementation planning, developing, and training, and by demonstrating their competency prior to using the MAK system. Operational Findings:
Related Recommendations (1)
R3
Submit regular reports that evaluate the overall effectiveness and efficiency of the MAK system and recommend areas for system improvement to the Medical Center Board of Directors.
F4
The clinician can stop the medication administration process if there is an error in the prescription, dosage, or bar code reconciliation. They then verify, reconcile, and/or override the system, and report the incident manually.
Related Recommendations (1)
R4
Contact other hospitals who use MAK and share ideas contributing to successful data gathering and reporting processes.
F5
Patients are informed by staff about the checks and balances performed before their medication is administered. Assessment and Evaluation Findings:
Related Recommendations (1)
R5
Evaluate the purchase of a Computerized Provider Order Entry (CPOE) module which allows physicians to coordinate with the MAK software module. San Mateo Medical Center’s Medication Administration Check System
Conclusions 3
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CL1 Page 4The San Mateo Medical Center (Medical Center) has promoted safety and more efficient methods for detecting and reducing medication administration-related errors at the hospital by implementing the Medication Administration Check (MAK) system. This system supports monitoring and alerting clinicians to potential medication administration-related errors, provides capability for reporting errors in medication administration, and involves patients in their own health care. The MAK implementation was well planned and executed.
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CL2 Page 4The Medical Center has no benchmarks or established baseline for comparison to quantitatively evaluate the effectiveness or the contribution to safety by the MAK system.
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CL3 Page 4The Medical Center has implemented a process that addresses safety and efficiency by ensuring clinicians are adequately trained and competent before using the MAK system. 4
No Responses Found 2
Government entities assigned to respond to this report. No response documents have been linked in our database.
County of San Mateo
Agency
San Mateo County Board of Supervisors
Elected County Office