STANDARD OPERATING PROCEDURE

VETERINARY HEALTH COMPLEX

Section: Administration Date of Issue: 3/10/2009

Issued By: Administration
Part: Medication Error Reporting Revision #: 1
Revision Date: 11/14/2012
Pages: Board Approval Date: 4/8/2009
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SOP #: 77

Description: It is the goal of the NC State Veterinary Health Complex (VHC) to provide an environment that insures that quality
patient care is delivered to the VHC patients. One component in providing for this environment involves the proper recording and
handling of medication errors. This standard operating procedure (SOP) establishes a medical error reporting system to both further
improvements in patient care and the overall learning experience of our staff and students. This is a voluntary system which promotes
a culture of safety, accountability, and self-growth. While data and trends will be monitored by a review committee, an emphasis will
not be placed on punitive outcomes. The emphasis will be placed on quality assurance, process improvements and training.

VHC Procedures:

Reporting Process: An electronic reporting system is accessible to VHC personnel through VHC Apps. This form provides
anonymity to the reporter and requests the following pieces of information:

• patient ID
• patient name
• client last name
• date of incident
• brief description of error or incident
• location of incident in hospital
• service area
• type of error
• personnel category committing error
• drug name
• number of doses administered incorrectly
• severity of error
VHC Outcome Categories
• As expected, no harm noted to patient; no treatment required to remedy
• Potentially could have caused prolonged therapy or morbidity; but no additional treatment required
• Caused prolonged therapy and/or minor morbidity
• Caused apparent significant morbidity
• Apparently cause of mortality or resulted in euthanasia
• End result unknown

VHC Use of Data

Once the error report is completed, the pharmacy director and assistant director of pharmacy will be notified by an automatically
generated email. Upon notification, the pharmacy director or a designate will review the error and assess the financial impact on
the VHC as well as on the client. The pharmacy director will also determine appropriate methods to prevent the error from
occurring again. All reported medication error incidents and outcomes will be collated in a read-only searchable database on VHC
apps. The Hospital Board will meet intermittently to review and trend the data. The review committee will be tasked to make
process improvement recommendations and/or training recommendations to insure the highest quality of patient care. VHC
administration and supervisors will review trends of repetitive errors involving the same employee and will exercise their
discretion in managing those unique situations.

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