Purpose: The current pharmacy occurrence-reporting system in an institution was reviewed, and an internal procedure that would provide data to improve the medication-use process was developed.
Summary: In a rural, 353-bed, tertiary care academic center, the effectiveness of a departmental occurrence-reporting system was determined over a nine-month period to increase occurrence reporting within the pharmacy and allow administrators to identify specific areas for improvement within the medication distribution process. These events were identified according to the number and type of near misses documented by pharmacy staff.