1 QUALITY IMPROVEMENT USING FOCUS-PDCA MODEL PHARMACY DEPARTMENT FIND OPPORTUNITY FOR IMPROVEMENT Medication Error 2 Jan Feb Mar Apr May Jun Jul Aug Sep 0 1 0 0 0 1 0 0 0 Organize a Team 3 Anu Augustian Abdul Kareem Chief Pharmacist Elizabeth Schulze Chief Nursing Officer Khairunnisa Shallwani Education and Training
Coordinator/ Quality Dept. Shaheena Surani Infection Control Coordinator/ Quality Dept. Haitham Naeem HOD- ER HOD- Pharmacy Rejimol Benny HOD- General Ward 2 Dr. Ammar Hassan Bincy Kurian General Practitioner Senior Executive- HR Clarify the current process 4 Uncover the Root Causes 5 The Quality Improvement Team identified many possible reasons through brain storming which is plotted using a fish bone model. FISHBONE DIAGRAM USED TO IDENTIFY ROOT CAUSES 6 People Lack of medication tracking Policy Fear of punishment No online system for medication administration No monitoring of policy Fear of consequences Effect on performance appraisal Professional threat Low self esteem
Lack of time No system in place Fear of punishment Lack of awareness of medication error Lack of awareness Lack of education Increase workload and less staff Increase turn over No time to read policy No audits by pharmacist Confusion between medication Error and near misses Fear of legal liabilities Error not consider worthy to report Fear of punishment Lack of standard procedures No regular feedback From pharmacy Fear No supervision during the Medication process No aware of the importance No risk management program Lack of improvement projects Under reporting Of Medication Error No orientation for doctor No process No audit No requirement Barriers in reporting medication error No enforcement to report error No competency checklist Threat of seniors Ineffective Communication Plant No open communication Fear of consequences/ Threat of losing the job Lack of Medication Error identification by patient Lack of patient / family education on Medication
error Lack of interest Process Root Cause Verification 7 To confirm the reasons and collect data the following techniques are used: -Personal Interview - Observation 8 Uncover/Verify Root Causes OCCURRENCE SL No Reasons No of Respons es 29 % Cumulat ive % 15.76 15.76 1 Increase workload 2 Fear of punishment 27 14.67 30.43 3 Fear of consequences 26 14.13 44.56 4
No regular feedback by pharmacy 24 13.04 57.6 5 Error not considered as error to report 18 9.78 67.38 6 No audit by pharmacy 14 7.61 74.99 7 No orientation regarding the process 12 6.52 81.51 8 Low self esteem 9 4.89 86.49 9 Unaware of policy 5 2.72 89.21 10 Lack of interest to report 5
2.72 91.93 11 No risk Management program 5 2.72 94.65 9 Uncover/Verify Root Causes OCCURRENCE SL No 12 13 14 Reasons No system in place No reinforcement by HOD Lack of awareness for Medical Error reporting TOTAL No of Respons es 5 3 % Cumulat ive % 2.72 1.63 97.37 99 2 1 100 184 Pareto Diagram Used to Verify Root Causes Number of Responses 10 35 30 25
67.38 74.99 81.51 97.37 99 91.93 94.65 89.21 86.49 57.6 20 44.56 15 30.43 10 15.76 5 0 s t e t y cy em rt cy ce ac ss or lic en OD am ... a l o e a n e r p o t H p p m p c e g
m s e p m e r y o r u r o e r sh re in of pr pr ha lfo tb w eq ni ha to or t m s p e e t r p n e u t e r s e r s e p t y a E or th on en as by re m w ys
of rr g ow m al e e re s fc it kb a e n L t c r c e c c i o d i a g a in d In Un or as No au ar ed Fe ar na db nf d of i o g a M e Fe e N r re ck re fe er o kM
fo n La id s ar o i s N l s ti r n a es gu co nt No en re t e r i o a or No w rn a o o f r N o Er ck a L o kl or 100 100 90 80 70 60 50 40 30 20 10 0 ad REASONS Series1
Series2 Select The Improvement Using The Solution Selection Matrix 11 Proposed Solutions 1. Ensure appropriate staffing 2. Train for Managing Time effectively 3. Ensure mix skill staff assignments to all units 4. Plan staff leaves ahead of time for Annual 5. Have a planner for leaves 6. Provide assuring and correct information regarding the process 7. Reduce the extent of punishments 8. Provide continues education as per hospital policies and procedures 9. Share the medication error cases within unit staff meetings 10. Encourage Medical Error reporting with positive feedback and less consequences 11. Plan monthly audit schedule for each unit 12. Provide monthly data to all unit heads regarding Medication error 13. Pharmacy must release quarterly action plan for the audit results 14. Spot checking by pharmacy for the proper medication usage process. 15. Offer medication safety session to all new staff and a refresher after 3 months 16. HOD will review Medication error and its types with staff as an ongoing process. Cost. is it cost effective Leadership Is time ? support? Practical? Acceptance effective 20 25 15 20 ? 20 80 125 90 100 120 80 125 105 100 120 100 50 150 100 120 120 200 150 100 120 120 200 150
620 Select The Improvement Using The Solution Selection Matrix 12 Proposed Solutions 17. Empower staff by timely and updated education regarding medication administration and medication safety Cost. is it cost Leadership Is time effective ? support? Practical? Acceptance effective ? 20 25 15 20 20 Total Score 900 18. Provide Channels to ventilate their anxieties and fears 120 140 200 150 150 90 100 100 120 140 690 620 19. HOD works as an advocate for her staff and provide support as required. 120 200 150 100 120 690 Plan the Improvement 13 Sl No
1 2 Areas of improvement Plan Responsible Person Fear of Punishment Reduce the extent of punishments CNO/ HOD/HR Error not considered as error to report/ No orientation Offer medication Safety session to all new staff and a refresher after 3 months OVR process flow to all units Pharmacy Educator HOD 3 Increase workload Plan staff leaves ahead of time: Annual HR CNO HOD Duty Managers 4 No regular feedback by pharmacy/ less frequent Audits Plan monthly audit schedule for each unit Pharmacy HOD 5 No regular feedback by pharmacy/ less frequent Audit Pharmacy must release
quarterly action plan for the audit results Pharmacy Cost Nil Date of Completion Nov. 2013 AED 1000 Ongoing Nov. 2013 Nil Nov. 2013 ongoing Nil Nov 2013 ongoing NIL Oct, 2013 ongoing Plan the Improvement 14 Sl No Areas of improvement Plan Responsible Person Cost Date of Completion Low self esteem Empower staff by timely and updated education regarding medication administration and medication safety Educator HOD CNO Nil
NOV 2013 On going Low self esteem HOD works as an advocate for her staff and provide support as required HOD CNO Nil Nov. 2013 on going Fear of Punishment/ Consequences Share the medication error cases with in unit staff meetings and during Medication safety sessions CNO Educator Pharmacy HR Nil Nov. 2013 on going 9 Fear of Punishment/ Consequences Provide continuous education as per hospital policies and procedures Educator HOD HR Nil Nov. 2013 on going 10 Fear of Punishment/ Consequences Encourage Medication Error reporting with positive feedback and less consequences.
HOD CNO HR Nil Nov. 2013 on going 6 7 8 Plan the Improvement 15 Areas of improvement Plan 11 Less frequent Audit / No regular feedback by Pharmacy Spot checking by pharmacy for the proper medication usage process Provide monthly data to all unit heads regarding Medication Error Quality Dept. Pharmacy Nil Dec. 2013 ongoing 12 Error not considered as error to report/ No orientation HOD will review medication error and its types with staff as an on going process HOD Duty Managers Nil Dec. 2013 ongoing
13 Low self esteem Provide channels to ventilate their anxieties and fears HOD CNO Duty Managers Nil Dec. 2013 ongoing 14 Increase workload Train for managing Time Effectively HR Educator HOD Nil Nov. 2013 Sl No Responsible Person Cost Date of Completion Plan the Improvement 16 Sl No Areas of improvement 15 Fear of Punishment/ Consequences Share the medication error cases within unit staff meetings HOD HR CNO Nil Nov. 2013
Ongoing 16 Increase workload Ensure mix skill staff assignments in all units CNO HR HOD Nil Nov 2013 Increase workload Ensure appropriate staffing Introduce training for staffing plan as per unit requirement CNO HR HOD Educator Nil Encourage staff to verbalize their issues of reporting Head nurse encourage staff to report HOD Nil 17 18 Low self esteem Plan Responsible Person Cost Date of Completion Nov 2013 2014 Planner Nov 2013 Do 17
Some Planned Solutions were implemented over a period of two months and the others are on going. Check did it works? 18 Medication Error Report BEFORE AFTER Improvement Noticed 19 Medication error reporting has been increased Support system is available for staff to ventilate their feeling Audit schedule planned Sharing of medication error report on quarterly bases Action plan by pharmacy was shared and will be done on regular bases Act: Maintain the Gain 20 Ongoing education Support system for staff to share their fears and anxiety Staff is aware of different types of medication errors and knows how to report: noted during session. Audits & reports by pharmacy 21 THANK YOU!!!
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