Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Plan do-study-act


Published on

Published in: Health & Medicine, Business

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.