Case study · Hoag Hospital

They targeted the errors their own data flagged – and cut them 60%.

Hoag built clinical scenarios around its own medication-error patterns and measured the result against its own baseline. Medication errors fell 60% – and the reduction repeated the following year.

60%

Fewer medication errors

2 yrs

Reduction repeated the following year

Pre/post

Measured against their own baseline

QI

Run as a quality-improvement project

Custom

Scenarios built to Hoag’s own error data

See the case

Measured against their own baseline

The challenge

The error happens at
the decision, not the policy.

Medication-related events sit among the largest categories of preventable harm – yet they rarely come from not knowing the policy. They come from the decision under load: dosing under time pressure, an interruption mid-administration, a reconciliation call at handoff. Completion-based training can show who finished a module, but not whether that decision changed at the bedside.

The approach

Built for the problem,
run like a study.

Hoag didn’t add another e-learning course. They built OMS scenarios around the specific medication-error patterns its own data had flagged, then ran them as a quality-improvement project – a named clinical endpoint, measured pre and post against their own baseline rather than against attendance.

The results

What changed.

Medication errors leading to harm fell 60%, measured against Hoag’s own baseline. The endpoint wasn’t a completion rate or a satisfaction score – it was a clinical event rate the quality team and board already track, moved by training that was targeted at the exact decisions where harm occurs. And it held: the reduction repeated the following year, against the same baseline – not a one-year effect.

What they practiced

The high-risk decisions,
where they happen.

The scenarios put clinicians in the moments medication errors actually occur and captured the decisions they made. Not a multiple-choice check, but the real failure points, practiced and measured.

60%

How we know

The work was run inside Hoag as a quality-improvement project – scenarios targeted to the hospital’s own medication-error patterns, with the error rate measured before and after against its own baseline, then again the following year. The result is pending publication, and the full Hoag methodology brief is available on request.

Common questions

Answered, plainly.

Custom OMS scenarios targeting Hoag’s own medication-error patterns were associated with a 60% reduction in errors, measured against the hospital’s own baseline. The reduction repeated the following year.

Yes. The 60% reduction was not a one-year effect – it repeated the following year, measured against the same baseline.

As a quality-improvement project: a named clinical endpoint, the medication-error rate, measured pre and post against Hoag’s own baseline, rather than course completion or satisfaction.

The scenarios put clinicians in the moments where medication errors occur and captured the decisions they made.

OMS is a clinical simulation platform where nurses make real clinical decisions in immersive scenarios, capturing how they reason as data – the workforce infrastructure a health system can measure and manage.

The conversation

See what this looks
like in your system.

We’ll walk through how Hoag built and measured it – and map the high-risk medication decisions to your own safety data, using your numbers, not ours.