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 opport...
Define the Plan-Do-Study-Act
 Stage 1: Plan: Identify an opportunity, and plan for
improvement
 Assemble the team
 Crea...
Step 2: Do
 Start carrying out your plan
 Test the theory for improvement
 Carry out the plan you’ve developed
 Collec...
Step 3: Study
 Examine your results
 Did the results match the theory/predictions
 Are there trends? Unintended side ef...
Step 4: Act
 Continue to examine and re-examine your process
using the PDSA cycle, by standardizing the
improvement or de...
P-D-S-A and Medication Errors
 Plan-
 The team (Root-cause analysis team)
 (Aim statement)- Decrease potential overdosi...
 Do:
 Require 2 nurses (1) must be RN to double check any override after
pharmacy hours.
 This requirement is also requ...
 Study:
 Pharmacy receives printout of all overrides daily. This
list is reviewed with actual order/situation to validat...
 Act:
 Nurse manager notified of any discrepancies in practice
 Any medications errors as a result of overrides
continu...
Plan do-study-act
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Plan do-study-act

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Plan do-study-act

  1. 1. Presented by: White River Medical Center Robin Anderson BSN, Michelle Bishop MSN NEA, Valerie Ragsdell RN
  2. 2. 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.
  3. 3. Define the Plan-Do-Study-Act  Stage 1: Plan: Identify an opportunity, and plan for improvement  Assemble the team  Create an aim Statement  Examine the current approach  Identify Potential Solutions
  4. 4. 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 effects
  5. 5. Step 3: Study  Examine your results  Did the results match the theory/predictions  Are there trends? Unintended side effects?  Is there an improvement?
  6. 6. 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 external customers  Take steps to preserve your gains and sustain your accomplishments
  7. 7. P-D-S-A and Medication Errors  Plan-  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
  8. 8.  Do:  Require 2 nurses (1) must be RN to double check any override after pharmacy hours.  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
  9. 9.  Study:  Pharmacy receives printout of all overrides daily. This list is reviewed with actual order/situation to validate if appropriate override.  Review all medication errors and report those related to overrides.
  10. 10.  Act:  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.
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