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Table 5 Top 20 interventions of 123 interventions implemented

From: Using Positive Deviance to reduce medication errors in a tertiary care hospital

Top 20 interventions implemented
1. double-checking of vasoactive drugs 11. purchase carts for nurses to prepare medicines at patients’ bedsides
2. double-checking of insulin 12. reminder implemented to avoid loss of drugs in the transfer between units
3. double-checking of multi-dose psychoactive medications 13. morphine doses greater than 6 mg prepared exclusively by pharmacy
4. double-checking of medications administered via infusion pump at the time of administration 14. sound and look alike drugs stored in different places
5. packaging of sterile petroleum jelly from ampoules to refillable bottle to prevent erroneous intravenous administration 15. high box use (capital letters) in the bar code identification and in the medical prescription and in the prescription for the medications sound alike look alike (ETILEfrine vs EPINEPHrine)
6. reminder was implemented to perform medication reconciliation when patients were transferred between units 16. Require prescription of drugs in doses rather than unit (tablet, vial, ampoule)
7. double checking medical prescription between nurses during shift changes 17. patient education for the conference identification bracelet with prescription at the time of drug administration
8. standardization in the medical team to change drug infusion rates 18. reinforcement for nursing staff for the immediate return of drugs suspended
9. reminder implemented for patient allergy insertion into the prescription form 19. change the color label for compounded drugs
10. insertion into prescription by pharmacist the diluent volume and rate of infusion of medications that may cause phlebitis 20. challenge units to increase reporting of medication errors