Presented by: White River Medical Center
Robin Anderson BSN, Michelle Bishop MSN NEA, Valerie Ragsdell RN
Objectives: The Participant will:
Define the 4 step Plan-Do Study-Act concept (PDSA)
Explain the definition and opportunities of each step
Describe the how the 4-step process can be used to
prevent medication errors.
Define the Plan-Do-Study-Act
Stage 1: Plan: Identify an opportunity, and plan for
Assemble the team
Create an aim Statement
Examine the current approach
Identify Potential Solutions
Step 2: Do
Start carrying out your plan
Test the theory for improvement
Carry out the plan you’ve developed
Collect, chart and display data
Document problems, unexpected observations, side
Step 3: Study
Examine your results
Did the results match the theory/predictions
Are there trends? Unintended side effects?
Is there an improvement?
Step 4: Act
Continue to examine and re-examine your process
using the PDSA cycle, by standardizing the
improvement or developing a new theory, and
establishing future plans.
Establish Future plans
Communicate your accomplishments to internal and
Take steps to preserve your gains and sustain your
P-D-S-A and Medication Errors
The team (Root-cause analysis team)
(Aim statement)- Decrease potential overdosing or
medication errors when pharmacy is closed
Current approach-any nurse allowed to override after
pharmacy hours 11pm-6am.
Overrides are entered on the PIXIS system by nurse
This process does not require a double check system, making
room for errors.
Change available dosing to match most common dose
Example: Hydomorphone current available=4mg/vial
Require 2 nurses (1) must be RN to double check any override after
This requirement is also required during the day during pharmacy
hours during crisis or trauma
Policy states any overrides during pharmacy hours must be
validated by emergent.
Change available dosing of Hydromorphone to match most
common dosing: 1mg/vial
Pulling multiple vials should always be a flag to nurse
Pharmacy receives printout of all overrides daily. This
list is reviewed with actual order/situation to validate if
Review all medication errors and report those related to
Nurse manager notified of any discrepancies in practice
Any medications errors as a result of overrides
continued to monitored for additional considerations
for process changes.