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 0 1 0 0 0 1 0 0 0

Medication Error

1 1
1

0 0 0 0 0 0 0
0
Jan Feb Mar Apr May Jun Jul Aug Sep
 Organize a Team
3

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
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 6

ROOT CAUSES
People

Lack of medication tracking

Policy Fear of punishment
No online system for medication Fear of consequences
administration
No monitoring of policy Effect on performance
Lack of time appraisal
Professional threat
No system in place Fear of punishment Low self esteem
Lack of awareness of medication error
Lack of awareness
Lack of education Confusion between medication
No time to read policy Increase workload and less staff Error and near misses
Increase turn over
No audits by pharmacist
Fear of legal liabilities
Error not consider worthy to report
Fear of punishment Under reporting
Of Medication
Lack of standard procedures Error
No regular feedback
From pharmacy
Fear No supervision during the Medication process
No aware of the
No risk management program importance No orientation for doctor
Lack of improvement projects No process
No audit
Barriers in reporting medication error No requirement
No enforcement to report error
Threat of seniors No competency checklist
Ineffective Communication
No open communication Lack of Medication Error identification by patient
Fear of consequences/ Lack of patient / family education on Medication
Plant Threat of losing the job error
Lack of interest

Process
 Root Cause Verification
7

To confirm the reasons and collect data the

following techniques are used:

-Personal Interview
- Observation
 Uncover/Verify Root Causes
8

OCCURRENCE
No of Cumulative
SL No Reasons %
Responses %
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
9

OCCURRENCE
No of Cumulative
SL No Reasons %
Responses %
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
Number of Responses
In
c re
as
ew
Fe

0
5
10
15
20
25
30
35
ar or
kl
of oa
No
Fe pu d
re ar n ish
Er gu
ro ar l of m
r fe co en

15.76
no
tc e ns t
db eq
on ac ue
s id kb nc
er yp es

30.43
ed ha
as rm
No er ac
r y
or N or
44.56
ie
nt o to
at au re
io di po
n t
57.6

by rt
re ph
ga
rd ar
in m
g ac
th y
67.38

ep
ro
Lo ce
w ss
74.99

se
Un lf-
es
La a w te
em
81.51

ck ar
No of e
in of
po

REASONS
ris te
kM re lic
stt y
an o
Causes

ag re
em po
en rt
86.49 89.21

La tp
ck No ro
of No sy gr
aw st am
91.93

ar re e
en i nf m
es or in
sf ce pl
m ac
or
M e nt e
ed by
ic a HO
lE D
94.65 97.37

rro
rr
ep
99

...
0
10
20
30
40
50
60
70
80
90
100 100
Pareto Diagram Used to Verify Root

Series2
Series1
 Select The Improvement Using The Solution Selection Matrix
Cost. is it
11 cost effective Leadership Is time Total
? support? Practical? Acceptance effective Score
Proposed Solutions 20 25 15 20 ? 20 900
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

12

Cost. is it
cost Leadership Is time Total
effective ? support? Practical? Acceptance effective ? Score
Proposed Solutions 20 25 15 20 20 900
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
13 Areas of Date of
Sl No Plan Responsible Person Cost
improvement Completion

Reduce the extent of

1 Fear of Punishment CNO/ HOD/HR Nil Nov. 2013
punishments

Offer medication Safety

session to all new staff
Error not considered Pharmacy AED
and a refresher after 3 Ongoing Nov.
2 as error to report/ Educator 1000
months 2013
No orientation HOD
OVR process flow to all
units
HR
Plan staff leaves ahead CNO Nov. 2013
3 Increase workload Nil
of time: Annual HOD ongoing
Duty Managers

No regular feedback Nov 2013

Plan monthly audit Pharmacy
4 by pharmacy/ less Nil ongoing
schedule for each unit HOD
frequent Audits

No regular feedback Pharmacy must release Oct, 2013

5 by pharmacy/ less quarterly action plan for Pharmacy NIL ongoing
frequent Audit the audit results
 Plan the Improvement
14 Areas of Date of
Sl No Plan Responsible Person Cost
improvement Completion
Empower staff by timely
and updated education Educator
NOV 2013
6 Low self esteem regarding medication HOD Nil
On going
administration and CNO
medication safety
HOD works as an
advocate for her staff HOD Nov. 2013 on
7 Low self esteem Nil
and provide support as CNO going
required
Share the medication
CNO
error cases with in unit Nov. 2013 on
Fear of Punishment/ Educator
8 staff meetings and Nil going
Consequences Pharmacy
during Medication safety
HR
sessions
Fear of Punishment/ Provide continuous Educator Nov. 2013 on
9 Consequences education as per hospital HOD Nil going
policies and procedures HR
Encourage Medication
Fear of Punishment/ HOD Nov. 2013 on
Error reporting with
10 Consequences CNO Nil going
positive feedback and
HR
less consequences.
 Plan the Improvement
15

Areas of Date of
Sl No Plan Responsible Person Cost
improvement Completion

Spot checking by
pharmacy for the proper
Less frequent Audit / medication usage
Quality Dept. Dec. 2013
11 No regular feedback process Nil
Pharmacy ongoing
by Pharmacy Provide monthly data to
all unit heads regarding
Medication Error
HOD will review
Error not considered
medication error and its HOD Dec. 2013
12 as error to report/ Nil
types with staff as an on Duty Managers ongoing
No orientation
going process

Provide channels to HOD

Dec. 2013
13 Low self esteem ventilate their anxieties CNO Nil
ongoing
and fears Duty Managers

HR
Train for managing Time
14 Increase workload Educator Nil Nov. 2013
Effectively
HOD
 Plan the Improvement
16

Areas of Date of
Sl No Plan Responsible Person Cost
improvement Completion

Share the medication HOD

Fear of Punishment/ Nov. 2013
15 error cases within unit HR Nil
Consequences Ongoing
staff meetings CNO

CNO
Ensure mix skill staff Nov 2013
16 Increase workload HR Nil
assignments in all units
HOD

Ensure appropriate
CNO Nov 2013
staffing
HR
17 Increase workload Introduce training for Nil
HOD
staffing plan as per unit
Educator 2014 Planner
requirement
Encourage staff to
verbalize their issues of
18 Low self esteem reporting HOD Nil Nov 2013
Head nurse encourage
staff to report
 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
Medication Error Medication Error
3
18 15
16 13
2 14
12

Number
10
1 1
8
1
6
4
0 0 0 0 0 0 0 2
0 0
Sep
Mar

May
Jan

Jun
Apr

Jul
Aug
Feb

Oct Nov
 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
 21

THANK YOU!!!