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1 MEDMARX Data Entry Training Katherine Jones, PhD, PT Anne Skinner, RHIA Supported by AHRQ Grant 1 U18 HS015822

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Page 1: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

1

MEDMARXData Entry Training

Katherine Jones, PhD, PTAnne Skinner, RHIA

Supported by AHRQ Grant 1 U18 HS015822

Page 2: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

2

Purpose of the Grant: Assist small rural hospitals to…

Voluntarily report and analyze medication errorsIdentify and analyze system sources of error

Compare current medication use system to best practices and prioritize changeConduct root cause analysis, failure mode and effect analysis

Implement and maintain organizational change

Page 3: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

3

Role of MEDMARX in the Project

Provides standardized terminology for data collection and analysisA critical tool to achieve the gold standard in QI: TELL A STORY WITH YOUR DATA

Source of benchmarks Overcomes rural barriers to QI

Small numbersLimited information management resourcesLimited human resources

Page 4: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

4

Role of MEDMARX in the Project

Use MEDMARX for Benchmarking againstAll MEDMARX recordsCritical Access HospitalsSimilar bed count

Use MEDMARX to compareError Severity Types of errorsCauses of errorsReporting by phase

Page 5: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

5

Role of MEDMARX in the Project

Detective workHas this error happened elsewhere?How often?In which size hospital?What level of staff was involved?What did they do about it?

Page 6: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

6

MEDMARX is a tool to enable us to stop seeing each error in isolation.

Page 7: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

7

Patient Safety Model (USP, 2004)

Data Collection

Culture

Data Analysis

Plan Change

Implement Change

Assess Impact of Change

MEDMARX

Page 8: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

8

MEDMARX Program

Internet accessible quality improvement tool that facilitates the anonymous collection of medication error information.Information is stored centrally in a data repository maintained by USP.Allows participating sites to report, track, and share medication error data in a standardized format.

Page 9: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

9

MEDMARX Program

Captures information about the error and steps taken in a facility to prevent recurrence.Participants can learn about causes and circumstances surrounding errors and prevent them from occurring in their facility.Sharing of knowledge and experience is a unique aspect of MEDMARX.

Page 10: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

10

MEDMARX Anonymity

Subscribing facilities are identified ONLY by a facility identification number randomly generated by MEDMARX.USP cannot identify facilities from which a record is submitted.Information and alerts are communicated through notices which maintains facility anonymity.

Page 11: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

11

MEDMARX Anonymity

Users must also play a role in protecting their anonymity.DO NOT include any identifiers in your records submitted to MEDMARX.

Facility ID, Facility Name, Abbreviation, or AcronymCity, State, National RegionYour name, Names of others in facilityNames of others involved in errorSocial Security NumbersMedical Record Numbers

Page 12: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

12

MEDMARX Administration

User AdministrationCreate a New UserEdit/Delete UsersChange PasswordsAssign appropriate level of access

Page 13: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

13

MEDMARX Administration

Facility ProfileVerify and update on regular basisCustomize location of error detail for your facility on the profile

Page 14: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

14

MEDMARX Data Entry Form

FormsMEDMARX Medication error data entry form vs. Medication Safety Reporting FormNotification of updates through MEDMARX NoticesForm Elements (See Error Record Fields Document)

• Error Category• Required Fields• Product Information• Additional fields

Page 15: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 16: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 17: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

17

MEDMARX MenuNotices

Public/Private NoticesMessages from UNMCSend Message to USP

RecordNewFind and Update/DeleteBatch Release

Page 18: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

18

MEDMARX MenuSearch

By Record NumberPredefined SearchesSaved SearchesCustom SearchGraphs/Charts

Page 19: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

19

Entering RecordsInterface Vocabulary

Picklists• Scrollable lists through which single or multiple items can

be selectedQuick Picks

• Used to quickly view and select items in a picklist.Checkboxes

• Select one or more choices.Radio buttons

• Allows only one choice.Text boxes

• Allows the typing of free text. Caution Maintain AnonymityUser-Defined Fields

• Enter data specific to your facility. Ex. Location of Error Detail, Internal Control, Miscellaneous

Page 20: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

20

Entering Records

Select Error Category

Enter Required FieldsLocation of Error Detail is a required field

Enter Product Information

Enter Additional Fields

Page 21: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 22: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

22

Record Administration

Holding/Releasing RecordsDO NOT release records to the general database

Locating/Updating/Deleting Held RecordsNew feature under Admin

Batch Update – both held and released records

• Action taken• Location detail

Page 23: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

23

Tips on Record Entry

Continuous approach to data entryDescription should cover what happened, when, why (if known), and outcome if applicableA vs B – why such a big deal?

From the patient’s perspective…A means no errorB means error occurred but was intercepted…a measure of success

Page 24: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

24

Category A Example

Patient admitted from ER. Admitting nurse made a new Med list from patient’s info and med bottles, but did not compare it to the med list in the clinic file. The meds missed from the clinic list included Calcium w/Vitamin D, Mobic and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor was the only one ordered, and was covered before the daily dose was due. Reporting nurse also noted to write out the home med list in layperson’s language, not abbreviations, and to omit unapproved abbreviations e.g. “qd” as “every day”.

Page 25: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

25

Category B Example

Xopenex and Atrovent Neb treatment ordered q 6hr without dose/strength of Xopenex indicated.

Root cause analysis summary: Physicians often let Pulmonary services complete the dose they want, but this leaves open the possibility that pharmacy might enter a different dose/strength in the computer. If Pulmonary doesn’t clarify order the order remains incomplete and can delay treatment.Action taken details: Informed staff who made the initial error (Physician)

Page 26: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

26

Feedback

Suggested updates e-mailed monthlyUNMC will change severities

Review each suggestionAgree?

Use Find and Update to make changesDisagree?

Don’t do anything – this is YOUR dataOR

Call or email to discuss

Page 27: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

27

MEDMARX Searches and Reports

Page 28: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

28

Searches

By Record NumberPredefined Searches - Spreadsheets

Director’s Report Spreadsheet for trending level of staff making

Error Outcome CategorySpreadsheet shows number and %age of errors by severity

Product Summary ReportSpreadsheet shows products involved in errors during specified time

Page 29: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 30: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 31: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 32: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

32

SearchesPredefined Searches - Spreadsheets

Summary ReportSpreadsheet shows severity, node, location of errors during specified time

Top Five Types of Error Drill Down*Spreadsheet shows top five error types and their top three causes, contributing factors, level of staff making error, and products involved during specified time(Hint: Split by Severity Category for a more informative report)

Top Five Generic Names Drill DownSpreadsheet shows top five generic names and their top three causes, contributing factors, level of staff making error, and products involved during specified time

*Included in quarterly report

Page 33: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

Search Category: Error Categories D-I, Sorted by Medication Process Node and Error Category

Page 34: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 35: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 36: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

36

Searches

Predefined Searches - GraphsTop Generic NamesTop Therapeutic ClassesTop Types of ErrorTop Causes of Error*

*Included in quarterly report

Page 37: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 38: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 39: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 40: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor
Page 41: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

41

Searches

Predefined Searches – Graphic TrendingCause of errorDay of weekMedication process nodeStaff-type initiated errorType of errorGeneric name

Caution: May not be useful!

*Included in quarterly report

Page 42: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

What’s wrong with this chart?

Page 43: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

43

Searches

Spreadsheet Tally by Month, Quarter, YearDate of ErrorError CategoryDesired Field (Type, Cause, Node, Location)

Total Number of Reports over time

Page 44: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

Criteria: Severity Categories C-I

Page 45: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

45

Custom Searches

Page 46: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

46

Custom Search

Example: Location of Error Detail not selected

Page 47: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

47

Custom Search

Results from custom searches can be used for Batch Updates – Location Detail and Actions Taken

Save your custom search for next time

Try it now!

Page 48: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

48

Quarterly Reports

Error Severity Over Time – Line ChartPercent of Errors by Severity – Stacked BarPercent of Errors by Process Node – Pie ChartError Type by Severity – Stacked BarTop Five Types of Error Drilldown -Spreadsheet Actions Taken WorksheetActions Taken by Severity*Top Causes of Error

Page 49: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

49

Error Severity Over Time

Error Severity Over TimeOctober 2005 - September 2006

0

100

200

300

400

500

600

700

Oct

05

Nov

05

Dec

05

Jan

06

Feb

06

Mar

06

Apr 0

6

May

06

Jun

06

Jul 0

6

Aug

06

Sep

06

# of

Err

ors

A B C D E-I 3 per. Mov. Avg.

Page 50: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

50

Percent of Errors by Severity

% of Errors By SeverityOctober 2005 - September 2006

22% 22% 18%9%

20% 23%20%

19%

53% 51%57%

68%

4% 3%1% 1% 4% 2%1% 2%

0%10%20%

30%40%50%60%70%

80%90%

100%

Qtr 4 2005 Qtr 1 2006 Qtr 2 2006 Qtr 3 2006

E-I

D

C

B

A

Page 51: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

51

Percent of Errors by Process Node

% of Errors (B-I) by Process NodeOctober 2005 - September 2006

Dispensing, 537, 14%

Prescribing, 335, 8%

Monitoring, 25, 1%

Procurement, 23, 1%

Administering, 1930,

48%

Transcribing/Documentin

g, 1102, 28%

Page 52: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

52

Error Type by Severity

Error Type by SeverityOctober 2005 - September 2006

0257

558

79 66 49 24 10 8 24 6 3 7216

329

95

19576 131

46 24 34 34 12 9 1 0

1049517

204

34177

44 30 6 1

11

0 0

1310

112

0

91 0 3 1 3 1 0 0

0

425

4023 3854

35

47

20 35

12

9 7 8 0 4 4

0

200

400

600

800

1000

1200

1400

Om

issi

on e

rror

Impr

oper

dose

/qua

ntity

Extra

dos

e

Una

utho

rized

/wro

ngdr

ug Wro

ng ti

me

Pres

crib

ing

erro

r

Wro

ng p

atie

nt

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e fo

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Wro

ng ro

ute

Mis

labe

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Dru

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Wro

ngad

min

istra

tion

tech

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e

Expi

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prod

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Det

erio

rate

d pr

oduc

t

# of

Err

ors

A B C D E-I

Page 53: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

53

Top Five Types of Error Drilldown

Type Of Error Top 3 Causes Top 3 Contributing Factors Top 3 Level of Staff, Made Top 3 Generic Names

Extra dose (653) * Documentation (493) Procedure/protocol not followed (73) Transcription inaccurate/omitted (45)

Does not apply (558) A contributing factor not determined (42) Workload increase (16)

Does Not Apply (558) Nurse, Registered (36) Nursing Personnel, non-specific (13)

Data Not Provided (75) Ipratropium and Albuterol (39) Acetaminophen (22)

Improper dose/quantity (586) Documentation (169) Transcription inaccurate/omitted (158) Procedure/protocol not followed (85)

Does not apply (257) A contributing factor not determined (161) None (49)

Does Not Apply (257) Nurse, Registered (106) Pharmacist (66)

Data Not Provided (149) Acetaminophen (24) Ipratropium and Albuterol (20)

Unauthorized/wrong drug (274) Documentation (69) Transcription inaccurate/omitted (59) Procedure/protocol not followed (52)

A contributing factor not determined (90) Does not apply (79) Workload increase (42)

Does Not Apply (79) Nurse, Registered (78) Pharmacist (34)

Data Not Provided (41) Ipratropium and Albuterol (17) Hydrocodone and Acetaminophen (9)

Omission error (216) Transcription inaccurate/omitted (60) Drug distribution system (47) Documentation (42)

A contributing factor not determined (83) No 24-hour pharmacy (43) None (32)

Nurse, Registered (97) Pharmacist (33) Nurse, Licensed Practical/Vocational (20)

Ipratropium and Albuterol (20) Potassium Chloride (12) Ceftriaxone (12)

Prescribing error (180) Documentation (32) Written order (32) Transcription inaccurate/omitted (23)

A contributing factor not determined (65) Does not apply (49) Workload increase (27)

Physician (96) Does Not Apply (49) Nurse, Registered (19)

Data Not Provided (23) Acetaminophen (10) Hydrocodone and Acetaminophen (10)

Top five types of error drilldown A-B

Page 54: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

54

Top Causes of ErrorTop Causes (All Error Severities)October 2005 - September 2006

1167

1009949

771

407299 294 277 228 214

0

200

400

600

800

1000

1200

1400

Per

form

ance

(hum

an) d

efic

it

Pro

cedu

re/p

roto

col

not f

ollo

wed

Doc

umen

tatio

n

Tran

scrip

tion

inac

cura

te/o

mitt

ed

Com

mun

icat

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Wor

kflo

wdi

srup

tion

Com

pute

r ent

ry

Kno

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dge

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it

MA

R v

aria

nce

Dru

g di

strib

utio

nsy

stem

# of

Rep

orts

Page 55: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

55

Actions Taken Worksheet

Record # Errorcategory

Date Description of error Type of error Cause of error Action taken Action taken detail

1162941 D 07/03/2006 order given for dobutamine stress test which was not done due to being unable to view cardiac images on echo. test was changed to nuclear stress test by physician. Meanwhile patient was take bac to ICU and returened after nuclear trace dose obtained. physician order was added to existing signed order and subsequently missed. dobutamine nuclear stree test performed insted of adenosine stress test.

Unauthorized/wrong drug

Communication; Preprinted medication order form; Written order

Policy/Procedure changed

1163659 G 07/06/2006 pyxis malfunction, RN did not call in pharmacist to correct problem, did not gove 0600 med.

Omission error

Dispensing device involved

Education/Training provided

RN will be counseled

1171237 F 07/13/2006 Doctor ordered Hydroxyzine 100mg IV , nurse gave med as ordered, med error route error. Explained to patient after med given, used to be given IV years ago. Explained to patient what side effects could occur. IV NS 1000ml given at Poison Control recommendation.

Wrong route Knowledge deficit Communication process enhanced; Education/Training provided; Informed patient's physician; Informed patient/caregiver of medication error; Informed staff who made the initial error; Informed staff who was also involved in error

Discussed with MD, Nurse, Patient and patient family. Will discuss at NDMD. Procedure in place to check med as it states on vial for IM use only. Reinforce following procedure.

Action Taken SpreadsheetAll CAHs, 07/01/2006 - 09/30/2006, Error categories D-I

Page 56: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

56

Actions Taken by Severity

Actions Taken By Error Severity3rd Quarter 2006

0 0 017 14

31

014

3 014

0

21

0 0 0

15 15

8

26

0

10

0

3

0 0 0

0 0

0

0

0

0

0

0

74

0

0

00

20

40

60

80

100

120

Staf

fing

prac

tice/

polic

ym

odifi

ed

Pol

icy/

Pro

cedu

rein

stitu

ted

Pol

icy/

Pro

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rech

ange

d Non

e

Info

rmed

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ff w

how

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Info

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Info

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nt/c

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of

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icat

ion

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Info

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pat

ient

'sph

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Form

ular

ych

ange

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Env

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mod

ified

Educ

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n/Tr

aini

ngpr

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Com

pute

rso

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ed/o

btai

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Com

mun

icat

ion

proc

ess

enha

nced

# of

Rep

orts

A-B C-D E-I

Page 57: MEDMARX Data Entry Training web - University of Nebraska ......and Effexor. Omission was picked up the next day by the 7-3 nurse comparing all the lists. Physician was notified, Effexor

57

Questions

MEDMARX Technical [email protected]

1-301-816-8561

Katherine [email protected]

402-559-8913

Anne [email protected]

402-559-8221


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