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We evaluated medication reconciliation processes of a qualitative case study at a 1000-bed public hospital. Lean tools were applied to identify factors contributing to prescribing errors and propose process improvement. Errors were attributed to the prescriber's skills, high workload, staff shortage, poor user attitude and rigid system function. Continuous evaluation of medication reconciliation efficiency is imperative to identify and mitigate errors and increase patient safety.

A Lean Approach to Evaluating Prescribing Errors in Medication Reconciliation