A systems approach to the problem of missing medications.

Overall, the systems approach employed in this study has significantly decreased the frequency of missing medication requests on one pharmacy satellite by 38 percent. The most dramatic impact came from the systems-change phase of the study. While the pharmacy personnel-change phase did not contribute to the overall reduction in missing medications, there was a large decrease in missing medications due to discrepancies between the nursing MAR and the pharmacy profile. This study has prompted further investigation into the p.r.n. drug-distribution subsystem.