​The pharmacy department noted several medication error event reports related to patients missing doses or receiving late doses.  Upon investigation they attributed this to an issue with stock-outs due to their ordering workflow. Attributing the stock-outs to their ordering workflow, Pharmacy implemented a kanban system for inventorying, which involves assigning a series of cards to each drug that indicates a specific order number and a precise order quantity—transforming the ordering process from being subjective into objective. Implementation of the kanban cards decreased stock-out occurrences by 32% over two years, helping ensure medications are available to patients at the time they are needed.​