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Reduction of medication errors in a department of Medicine Project participants: Ms. Pnina Sharon, RN, Mgr. Lenna Rothfeld and Prof. Arieh Ben-Yehuda Background: Medications errors are major threat to patient safety in hospital wards, for which awareness is a first essential step to prevention.1 Methods: A safety initiative by department Head, Prof. Arieh BenYehuda and the Head Nurse, Ms. Pnina Sharon, began in 2001 with a systematic documentation of medication errors, with special focus on discharge summaries, local intervention on processes and periodic reevaluation. Results: The completeness of orders details (such as date, timing, clear dosage and usage of capital letters for drug names) rose from 37% adherence to guidelines in year 2001 to 59% in 2002 and 88% in 2004. Using simple interventions such as double-check of physician’s orders by nurses on the night shift and feedback to physicians, a four-fold decrease of errors was documented over three years, Conclusion & future plan: Leadership is effective in promoting a culture of safety and reducing errors and may be a critical step for improving safety at the microsystem level.2 Diffusion of this example to other wards is being encouraged by presentations to department heads. 1 Kohn LT, Corrigan J, Donaldson MS. To err is human : building a safer health system Washington, D.C.: National Academy Press; 2000. 2 Leape LL, Berwick DM. Five Years After To Err Is Human: What Have We Learned? JAMA. 2005;293(19):2384-2390.