1. Quality Improvement Using FOCUS-PDCA MODEL
PHARMACY DEPARTMENT

2. Find Opportunity for Improvement
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Medication Error 1

3. Organize a Team 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

4. Clarify the current process

5. Uncover the Root Causes
The Quality Improvement Team identified many possible reasons through brain storming which is plotted using a fish bone model.

6. Fishbone Diagram used to Identify Root Causes

7. Root Cause Verification
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 Responses %
Cumulative % 1
Increase workload 29
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
Unaware of policy
2.72
89.21 10
Lack of interest to report
91.93 11
No risk Management program
94.65

9. Uncover/Verify Root Causes
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

10. Pareto Diagram Used to Verify Root Causes

11. Select The Improvement Using The Solution Selection Matrix
Proposed Solutions
Cost. is it cost effective ? 20
Leadership support? 25
Practical? 15
Acceptance
Is time effective ? 20
Total Score
900
1. Ensure appropriate staffing 80
125 90
100
120
515
2. Train for Managing Time effectively
105
530
3. Ensure mix skill staff assignments to all units 50
150
520
4. Plan staff leaves ahead of time for Annual
200
690
5. Have a planner for leaves
6. Provide assuring and correct information regarding the process
140
620
7. Reduce the extent of punishments
160
780
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. 60
420
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.

12. Select The Improvement Using The Solution Selection Matrix
Proposed Solutions
Cost. is it cost effective ? 20
Leadership support? 25
Practical? 15
Acceptance 20
Is time effective ?
Total Score
900
17. Empower staff by timely and updated education regarding medication administration and medication safety
120
200
150
100
690
18. Provide Channels to ventilate their anxieties and fears
140 90
620
19. HOD works as an advocate for her staff and provide support as required.

13. Plan the Improvement 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
Duty Managers
ongoing 4
No regular feedback by pharmacy/ less frequent Audits
Plan monthly audit schedule for each unit
Nov 2013 5
No regular feedback by pharmacy/ less frequent Audit
Pharmacy must release quarterly action plan for the audit results
NIL
Oct, 2013

14. Plan the Improvement 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
HOD works as an advocate for her staff and provide support as required
Nov on going 8
Fear of Punishment/ Consequences
Share the medication error cases with in unit staff meetings and during Medication safety sessions
Pharmacy HR 9
Provide continuous education as per hospital policies and procedures 10
Encourage Medication Error reporting with positive feedback and less consequences.

15. Plan the Improvement 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 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 13
Low self esteem
Provide channels to ventilate their anxieties and fears
CNO 14
Increase workload
Train for managing Time Effectively HR
Educator
Nov. 2013

16. Plan the Improvement 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 Ongoing 16
Increase workload
Ensure mix skill staff assignments in all units
Nov 2013 17
Ensure appropriate staffing
Introduce training for staffing plan as per unit requirement
Educator
2014 Planner 18
Low self esteem
Encourage staff to verbalize their issues of reporting
Head nurse encourage staff to report

17. Do
Some Planned Solutions were implemented over a period of two months and the others are on going.

18. Check did it works?
Medication Error Report
BEFORE AFTER

19. Improvement Noticed 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

20. Act: Maintain the Gain 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!!!