ERIC EVANGELISTA TQM Dean Valderama 9-10-2013 Goal: To enhance patient safety by establishing or updating the medication safety

protocol and to enhance medication reconciliation and reduce medication errors in the department. Analyze the system - How will you know that a change is important? To adopt a system oriented approach that will be implemented along with a check list system of monitoring that a health personnel can audit every shift during endorsement periods. Rapid - cycle small scale tests of changes in the system - What changes can we make that will result in improvement? By implementing a system oriented standard that involves a multi-disciplinary approach, along with a computerized generated system of monitoring medication needs. The levels of errors should be reduced to a minimum to none and help create an environment that is both patient oriented and also care that is multilevel approach. CQI REPORT Background The setting is a medical/surgical unit at V.LUNA, Physicians, Nurses, Pharmacist, and healthcare personnel. Problem - What are you trying to accomplish? Implement appropriate, well-designed safety processes and "systems" broadly and consistently to reduce medication errors to ensure patient safety. Key measures for improvement - What would constitute improvement in view of the patients. Improvement of patient satisfaction by reducing medication errors and improve health conditions of clients.

Stategies for Change Principle for reducing medication errors: - Incorporation of principles to reduce human error into the design of work that can greatly reduce the likelihood of error and increase the chance of intercepting errors before harm to the patient. These include such strategies as standardization, simplification, care bundles and use of computers. - Promote a non-punitive atmosphere for reporting of errors which values the sharing of information about the causes of errors and strategies for prevention. - Maintain unit-dose distribution systems (either manufacturer prepared or repackaged by pharmacy) for all non-emergency medications - Institute pharmacy-based IV admixture systems.Information on new drugs, infrequently used drugs, and non-formulary drugs should be made easily accessible to clinicians prior to ordering, dispensing, and administering medications. - Develop special procedures for high-risk drugs using a multi-disciplinary approach. These include written guidelines, checklists, pre-printed orders, doublechecks, special packaging, special labeling, and education. - Remove concentrated potassium chloride (KCl) vials from nursing units and patient care areas. Stock only diluted premixed IV solutions on units (MHA, 1999) Effect of Change - Did the strategies lead to improvement? How did you know? At this point the implementation of the above strategies have not been established, so the effects of change is unknown. If this recommendations were implemented the goal would be to improve patient safety and reduce medications

errors at administration. Lessons Learned - What have you learned/achieved and how will you take this forward? I learned that a multi-disciplinary approach is needed in achieving an improved way to handling medication safety guidelines and reducing medication errors both in department and hospital setting.

REFERENCES: Best Practice Recommendations to Reduce Medication Errors The Coalition's first initiative the prevention of medication errors is based on the. Massachusetts Hospital Association's (MHA) medication error prevention 1999 .www.macoalition.org/documents/Best_Practice_Medication_Errors.pdf