FOUCS - PDCA
QUALITY IMPROVEMENT USING
FOCUS-PDCA MODEL
PHARMACY DEPARTMENT
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FIND OPPORTUNITY FOR IMPROVEMENT
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| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | |
| Medication Error | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 0 |
Organize a Team
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- Anu Augustian HOD- Pharmacy
- 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
- Rejimol Benny HOD- General Ward 2
- Dr. Ammar Hassan General Practitioner
- Bincy Kurian Senior Executive- HR
Clarify the current process
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Uncover the Root Causes
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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
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Under reporting Of Medication Error
Policy
People
Plant
Process
No supervision during the Medication process
No orientation for doctor
No process
No requirement
No competency checklist
Lack of Medication Error identification by patient
Lack of patient / family education on Medication error
Lack of interest
No regular feedback From pharmacy
No aware of the importance
No audit
No enforcement to report error
Ineffective Communication
No open communication
Fear of consequences/ Threat of losing the job
Lack of standard procedures
Fear
No risk management program
Lack of improvement projects
Barriers in reporting medication error
Threat of seniors
No monitoring of policy
No system in place
Lack of awareness
No time to read policy
No audits by pharmacist
Lack of medication tracking
No online system for medication administration
Lack of time
Fear of punishment
Lack of awareness of medication error
Lack of education
Increase workload and less staff
Increase turn over
Fear of legal liabilities
Error not consider worthy to report
Fear of punishment
Fear of punishment
Fear of consequences
Effect on performance appraisal
Professional threat
Low self esteem
Confusion between medication Error and near misses
Root Cause Verification
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- To confirm the reasons and collect data the following techniques are used:
-Personal Interview
- Observation
Uncover/Verify Root Causes
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| OCCURRENCE | ||||
| SL No | Reasons | No of Responses | % | Cumulative % |
| 1 | Increase workload | 29 | 15.76 | 15.76 |
| 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 |
Uncover/Verify Root Causes
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| OCCURRENCE | ||||
| SL No | Reasons | No of Responses | % | Cumulative % |
| 12 | No system in place | 5 | 2.72 | 97.37 |
| 13 | No reinforcement by HOD | 3 | 1.63 | 99 |
| 14 | Lack of awareness for Medical Error reporting | 2 | 1 | 100 |
| TOTAL | 184 |
Pareto Diagram Used to Verify Root Causes
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Chart4
| Increase workload | Increase workload |
| Fear of punishment | Fear of punishment |
| Fear of consequences | Fear of consequences |
| No regular feedback by pharmacy | No regular feedback by pharmacy |
| Error not considered as error to report | Error not considered as error to report |
| No audit by pharmacy | No audit by pharmacy |
| No orientation regarding the process | No orientation regarding the process |
| Low self-esteem | Low self-esteem |
| Unaware of policy | Unaware of policy |
| Lack of interest to report | Lack of interest to report |
| No risk Management program | No risk Management program |
| No system in place | No system in place |
| No reinforcement by HOD | No reinforcement by HOD |
| Lack of awareness for Medical Error reporting | Lack of awareness for Medical Error reporting |
Sheet1
| REASON | NO. OF RESPONSES | % | C. % |
| Increase workload | 29 | 15.76 | 15.76 |
| Fear of punishment | 27 | 14.67 | 30.43 |
| Fear of consequences | 26 | 14.13 | 44.56 |
| No regular feedback by pharmacy | 24 | 13.04 | 57.6 |
| Error not considered as error to report | 18 | 9.78 | 67.38 |
| No audit by pharmacy | 14 | 7.61 | 74.99 |
| No orientation regarding the process | 12 | 6.52 | 81.51 |
| Low self-esteem | 9 | 4.89 | 86.49 |
| Unaware of policy | 5 | 2.72 | 89.21 |
| Lack of interest to report | 5 | 2.72 | 91.93 |
| No risk Management program | 5 | 2.72 | 94.65 |
| No system in place | 5 | 2.72 | 97.37 |
| No reinforcement by HOD | 3 | 1.63 | 99 |
| Lack of awareness for Medical Error reporting | 2 | 1 | 100 |
| TOTAL | 184 |
Sheet1
Sheet2
Sheet3
Select The Improvement Using The Solution Selection Matrix
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| Proposed Solutions | Cost. is it cost effective ? 20 | Leadership support? 25 | Practical? 15 | Acceptance 20 | Is time effective ? 20 | Total Score 900 |
| 1. Ensure appropriate staffing | 80 | 125 | 90 | 100 | 120 | 515 |
| 2. Train for Managing Time effectively | 80 | 125 | 105 | 100 | 120 | 530 |
| 3. Ensure mix skill staff assignments to all units | 100 | 50 | 150 | 100 | 120 | 520 |
| 4. Plan staff leaves ahead of time for Annual | 120 | 200 | 150 | 100 | 120 | 690 |
| 5. Have a planner for leaves | 120 | 200 | 150 | 100 | 120 | 690 |
| 6. Provide assuring and correct information regarding the process | 140 | 150 | 90 | 100 | 140 | 620 |
| 7. Reduce the extent of punishments | 160 | 200 | 120 | 160 | 140 | 780 |
| 8. Provide continues education as per hospital policies and procedures | 140 | 150 | 90 | 100 | 140 | 620 |
| 9. Share the medication error cases within unit staff meetings | 80 | 125 | 105 | 100 | 120 | 530 |
| 10. Encourage Medical Error reporting with positive feedback and less consequences | 140 | 150 | 90 | 100 | 140 | 620 |
| 11. Plan monthly audit schedule for each unit | 120 | 200 | 150 | 100 | 120 | 690 |
| 12. Provide monthly data to all unit heads regarding Medication error | 140 | 150 | 90 | 100 | 140 | 620 |
| 13. Pharmacy must release quarterly action plan for the audit results | 120 | 200 | 150 | 100 | 120 | 690 |
| 14. Spot checking by pharmacy for the proper medication usage process. | 80 | 100 | 60 | 80 | 100 | 420 |
| 15. Offer medication safety session to all new staff and a refresher after 3 months | 160 | 200 | 120 | 160 | 140 | 780 |
| 16. HOD will review Medication error and its types with staff as an ongoing process. | 140 | 150 | 90 | 100 | 140 | 620 |
Select The Improvement Using The Solution Selection Matrix
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| Proposed Solutions | Cost. is it cost effective ? 20 | Leadership support? 25 | Practical? 15 | Acceptance 20 | Is time effective ? 20 | Total Score 900 |
| 17. Empower staff by timely and updated education regarding medication administration and medication safety | 120 | 200 | 150 | 100 | 120 | 690 |
| 18. Provide Channels to ventilate their anxieties and fears | 140 | 150 | 90 | 100 | 140 | 620 |
| 19. HOD works as an advocate for her staff and provide support as required. | 120 | 200 | 150 | 100 | 120 | 690 |
Plan the Improvement
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| Sl No | Areas of improvement | Plan | Responsible Person | Cost | Date of Completion |
| 1 | Fear of Punishment | Reduce the extent of punishments | CNO/ HOD/HR | Nil | Nov. 2013 |
| 2 | 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 | AED 1000 | Ongoing Nov. 2013 |
| 3 | Increase workload | Plan staff leaves ahead of time: Annual | HR CNO HOD Duty Managers | Nil | Nov. 2013 ongoing |
| 4 | No regular feedback by pharmacy/ less frequent Audits | Plan monthly audit schedule for each unit | Pharmacy HOD | Nil | Nov 2013 ongoing |
| 5 | No regular feedback by pharmacy/ less frequent Audit | Pharmacy must release quarterly action plan for the audit results | Pharmacy | NIL | Oct, 2013 ongoing |
Plan the Improvement
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| Sl No | Areas of improvement | Plan | Responsible Person | Cost | Date of Completion |
| 6 | Low self esteem | Empower staff by timely and updated education regarding medication administration and medication safety | Educator HOD CNO | Nil | NOV 2013 On going |
| 7 | Low self esteem | HOD works as an advocate for her staff and provide support as required | HOD CNO | Nil | Nov. 2013 on going |
| 8 | 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 |
Plan the Improvement
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| Sl No | Areas of improvement | Plan | Responsible Person | Cost | Date of Completion |
| 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 |
Plan the Improvement
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| Sl No | Areas of improvement | Plan | Responsible Person | Cost | Date of Completion |
| 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 |
| 17 | Increase workload | Ensure appropriate staffing Introduce training for staffing plan as per unit requirement | CNO HR HOD Educator | Nil | Nov 2013 2014 Planner |
| 18 | Low self esteem | Encourage staff to verbalize their issues of reporting Head nurse encourage staff to report | HOD | Nil | Nov 2013 |
Do
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- Some Planned Solutions were implemented over a period of two months and the others are on going.
Check did it works?
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Medication Error Report
BEFORE AFTER
Improvement Noticed
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- 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
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- 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
THANK YOU!!!
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Under reporting
Of Medication
Error
Policy
People
Plant
Process
No supervision during the Medication process
No orientation for doctor
No competency checklist
Lack of Medication Error identification by patient
No process
No requirement
Lack of patient / family education on Medication
error
Lack of interest
No regular feedback
From pharmacy
No aware of the
importance
No audit
No enforcement to report error
Ineffective Communication
No open communication
Fear of consequences/
Threat of losing the job
Lack of standard procedures
Fear
No risk management program
Lack of improvement projects
Barriers in reporting medication error
Threat of seniors
No monitoring of policy
No system in place
Lack of awareness
No time to read policy
No audits by pharmacist
Lack of medication tracking
No online system for medication
administration
Lack of time
Fear of punishment
Lack of awareness of medication error
Lack of education
Increase workload and less staff
Increase turn over
Fear of legal liabilities
Error not consider worthy to report
Fear of punishment
Fear of punishment
Fear of consequences
Effect on performance
appraisal
Professional threat
Low self esteem
Confusion between medication
Error and near misses
15.76
30.43
44.56
57.6
67.38
74.99
81.51
86.49
89.21
91.93
94.65
97.37
99
100
0
5
10
15
20
25
30
35
Increase workload
Fear of punishment
Fear of consequences
No regular feedback by pharmacy
Error not considered as error to report
No audit by pharmacy
No orientation regarding the process
Low self-esteem
Unaware of policy
Lack of interest to report
No risk Management program
No system in place
No reinforcement by HOD
Lack of awareness for Medical Error rep...
REASONS
Number of Responses
0
10
20
30
40
50
60
70
80
90
100
Series1
Series2