Medication use systems in hospitals, often depending on intricate organizational systems and subsystems, are complex and prone to error. According to Johns Hopkins SoN faculty member Jo M. Walrath and nursing colleagues at The Johns Hopkins Hospital, "This complexity, along with the sheer volume of medications given to patients, opens the way for error and reinforces the need for a major redesign of [medication use systems] within hospital settings."

In an article published in the January-March issue of the Journal of Nursing Care Quality, Walrath and colleagues describe efforts to redesign the medical use system for The Johns Hopkins Hospital, one of the nation's largest hospitals. The redesign effort, now in the implementation stage, used idealized design methodology as a starting point for preventing patient harm from medication errors.

The interdisciplinary team directing the effort identified systems properties, proposed and gathered feedback on an ideal design and established a structure to plan changes in the system and to monitor the impact of changes.

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