Total quality management in action: pharmacy system changes to decrease medication incidents and increase clinical services.

During a monitoring of risk management indicators (incident report analysis), a trend of increasing medication incidents was noted from 1987 to 1990. The medication ordering process was tracked using a flow chart, and, using an interdisciplinary team, the transcription system was targeted for corrective action. A "roving pharmacist" system was devised, with a resultant 63% decrease in the reported medication incident rate from 1990 to 1993.