Discussion 1 by Sravya Patil Bagli  (a) What is the purpose of what this study is trying to accomplish? This article addresses underreporting of medication errors by the employees of Medcare hospital. The purpose of this study was to explore medication error reporting rate and determine reasons why Quality Management Department (QMD) was not receiving the reports. Also, the intent was to identify and correct the barriers and attitudes among staff that are preventing them from reporting the errors. Thereby, facilitating the issues that helps in improvement of patient safety and achieving better health care (Jacobson, 2015). (b) What is the process(es) or activities involved in the response to a? Medcare has selected nine members based on their involvement in the error reporting to form a team. They are involved in a model called FOCUS PDCA (PDCA = Plan, Do, Check, Act). Firstly, the team worked together to find out the causes for errors and clarify the error reporting process and later, the team interviewed the staff to know the reasons for underreporting. In the second step, the team developed solutions and ranked them to highlight the most effective ones. The highest-ranked were then incorporated into the action plan. The final step was to focus on improvement - everyone participated to continue the proposed solutions and checked the room for improvement. Since then, a drastic improvement has been evident in the error reporting of Medcare indicating that the study was successful. (c) What is the purpose of measuring and reporting performance? The purpose of measuring performance is to encourage individual productivity in the organization and to improve work efficiency. It helps to eliminate the unproductive employees and recognizes the strong performers and continue to motivate them. Also, it helps the organization understand how decision-making process led to success or failure in the past and how that understanding would help to make further improvements. (d) What is the purpose of reporting quality measurement data? The purpose of quality measurement is to examine the appropriateness of care and accuracy of the organization. It is generally known that quality is directly linked to improvement, it helps to discuss the link between measurement and improvement. Therefore, filling the gaps that compromised the ability of management to provide expected quality. Discussion 2 by Israel Moore  1. What is the purpose of what this study is trying to accomplish? The purpose of this study is to first acknowledge and bring awareness to the importance of reporting medical errors, as well as the importance of teamwork and developing a good solid strategy to overcome challenges.  a. What is the process(es) or activities involved in the response to a? The process included a few steps. First it focused on the importance of error detecting. Next, Medcare developed a strategic project team that included department head members. This team then collect.

1. Discussion 1 by Sravya Patil Bagli
(a) What is the purpose of what this study is trying to
accomplish?
This article addresses underreporting of medication errors by
the employees of Medcare hospital. The purpose of this study
was to explore medication error reporting rate and determine
reasons why Quality Management Department (QMD) was not
receiving the reports. Also, the intent was to identify and
correct the barriers and attitudes among staff that are preventing
them from reporting the errors. Thereby, facilitating the issues
that helps in improvement of patient safety and achieving better
health care (Jacobson, 2015).
(b) What is the process(es) or activities involved in the response
to a?
Medcare has selected nine members based on their involvement
in the error reporting to form a team. They are involved in a
model called FOCUS PDCA (PDCA = Plan, Do, Check, Act).
Firstly, the team worked together to find out the causes for
errors and clarify the error reporting process and later, the team
interviewed the staff to know the reasons for underreporting. In
the second step, the team developed solutions and ranked them
to highlight the most effective ones. The highest-ranked were
then incorporated into the action plan. The final step was to
focus on improvement - everyone participated to continue the
proposed solutions and checked the room for improvement.
Since then, a drastic improvement has been evident in the error
reporting of Medcare indicating that the study was successful.
(c) What is the purpose of measuring and reporting
performance?
The purpose of measuring performance is to encourage
individual productivity in the organization and to improve work
efficiency. It helps to eliminate the unproductive employees and
recognizes the strong performers and continue to motivate them.

2. Also, it helps the organization understand how decision-making
process led to success or failure in the past and how that
understanding would help to make further improvements.
(d) What is the purpose of reporting quality measurement data?
The purpose of quality measurement is to examine the
appropriateness of care and accuracy of the organization. It is
generally known that quality is directly linked to improvement,
it helps to discuss the link between measurement and
improvement. Therefore, filling the gaps that compromised the
ability of management to provide expected quality.
Discussion 2 by Israel Moore
1. What is the purpose of what this study is trying to
accomplish?
The purpose of this study is to first acknowledge and bring
awareness to the importance of reporting medical errors, as well
as the importance of teamwork and developing a good solid
strategy to overcome challenges.
a. What is the process(es) or activities involved in the response
to a?
The process included a few steps. First it focused on the
importance of error detecting. Next, Medcare developed a
strategic project team that included department head members.
This team then collected data and found the reasoning behind
why hospital staff did not report most medication errors. The
team used other techniques such as brainstorming strategies or
observation of the staff to help gather even more data behind
the medical errors. After collecting this data, the team
developed questions such as “is it cost effective?” to determine
if the solutions they had developed actually had the possibility
of being successful. Lastly, the team followed up to see if what
they had created actually worked for the organization.
1. What is the purpose of measuring and reporting performance?
The purpose of measuring and reporting performance is to be
able to track the progress of the new strategy being in place

3. with solid quantitative data. Its one thing to have information
from interviews or observations, but it is also equally as
important to have concrete numerical data to help show the
progress the organization. “Numbers do not lie.”
1. What is the purpose of reporting quality measurement data?
The purpose of reporting quality measurement data is so that
everyone will see the full picture to help improve the org. If
staff members are only reporting some of the medical errors or
none at all (because of fear of being in trouble, lack of interest,
etc.) than the team doesn’t have the necessary information to fix
the issues; because they only are aware of part of the problems
to solve, and not all of them.
Running Head: CONSERVATION OF THE SERENGETI
1
CONSERVATION OF THE SERENGETI
2
Portfolio Project Option 2: Conservation of The Serengeti
Jessica Amerie
BIO121- Environmental Conservation
Colorado State University- Global Campus
Professor Nathan Hovekamp
March 11, 2018
The Serengeti ecosystem is a game reserve in Africa located in
the Northern Tanzania and extending into Kenya in the South-
Western parts. The reserve spans about 12000 squared miles.
The Kenyan section of the Serengeti reserve is called Maasai
Mara.
The reserve is home to the biggest terrestrial mammal migration
in the whole world thereby securing it a slot in the list of the
seven natural wonders of the world, yet again appearing in the
list of the ten natural travel wonders of the world. The park is

4. also renowned for its huge lion population and is one of the
wonderful places to observe the pride in nature.
The park is home to about 70 large mammals and 500 species of
birds. This great diversity remains a function of diverse habitats
encompassing swamps, riverine forests, woodlands and
grasslands. Buffaloes, Zebras, gazelles and blue wildebeests are
some of the large mammals that the park is home to.
The ecology
The Serengeti harbors east Africans finest game areas. Other
than being renowned for the popular great migration, the park is
also popular for its abundant big predators. The ecosystem is
habitat to over 1000 leopards, 3000 lions and about 8700
spotted hyenas. However wild dogs are relatively scarce in the
region, wild dogs were reported to become extinct in the year
1992 with its predators the hyenas and lions being cited as the
direct cause to the extinction (Estes,2009).
The park is also home to many grazers including warthogs,
African buffalo, eland, grant gazelle and waterbuck. The park
can support this vast number of diversified species because each
of them has a different diet (Harris et al,2009). For instance,
Zebras graze on taller grass and wildebeest prefer shorter ones.
Similarly, dik-dik consumes the lowest branches of trees while
giraffe and impalas eat those that are higher up. The involved
governments that is the Kenyan and Tanzanian governments
give legal protection to the park and its reserves.
The role of humans in the Serengeti region
Much of the park was known as Maasailand by outsiders, the
Maasai communities also believed to be fierce warriors live
alongside the wild part of the region with an aversion of hunting
the birds and game exclusively subsisting on their cattle. Their

5. reputation and strength historically kept the Europeans from
exploiting the resources and animals of most of their land. A
Rinderpest epidemic reduced greatly the population of both the
game and the Maasai in 1890s. The government of Tanzania
later resettled the Maasai in the Ngorongoro crater (Kidegesho
et al.,2005).
The absence of poaching and forest fires which had been due to
human activity led to the development of thickets and dense
woodlands over the next 50 years. During the mid 1970s the
cape buffalos’ population and the wildebeest had recovered and
were cropping the grass again, thereby reducing the fuel amount
available for fires. Acacia has become established once again
due to the reduced intensity of fires. During the 21st century,
programs of mass vaccination of rabies for domestic dogs in
the region apart from preventing many human deaths have
protected also the wildlife species like the endangered African
dog.
The great migration
Every year around the same time, a circular migration of
wildebeest starts in the Ngorongoro conservation region in
Tanzania and follows a clockwise direction across the Serengeti
Park through the Maasai Mara reserve in Kenya. This great
migration is a natural phenomenon that is as a result of grazing
issues. The initial phase takes about three months from January
to March when the season of calving starts – a time when the
rain is in plenty and there is a lot of grass for the 1.7 million
wildebeest preceded by about 20,000 zebras and many other
plain game.
In February, the wildebeest feed on the short grass in the plains
and give birth to about 500,000 calves in a period of about 2-3
weeks. A few calves are born before time and not many of them
survive, reason being that they become noticeable to predators
and get prayed on. While the rains come to an end in May, the

6. animals trek towards the north along the Grumeti River where
they remain till the month of June. In July, the animals begin to
cross the Grumeti and the Mara River and become a popular
safari attraction. In late July, the herds arrive in Kenya and stay
up to August till the dry season is over. With the start of the
short rains in early November, the migration starts moving
towards the south again, usually arriving in December to feed
on the short grass plains in the south east and to calve. During
the journey form Tanzania to Kenya about 250 000 wildebeest
die due to hunger, predation and exhaustion.
Threats facing the natural area
The numbers of Warthog, giraffe, impala, hartebeest and topi
fell by about 50% between the year 19979 and 2002. This
decline is linked to rapid growth of human settlement around
the park according to a research done by the international
livestock research institute in a journal of zoology
(Kahurananga, & Silkiluwasha, 1997). This situation does paint
a bleak image and required decisive and urgent action if the
treasure has to be saved from the disaster. The loss of grazers is
already creating an impact to the lion population and the
cheetahs. The carnivores are the first casualties since they
depend on this wildlife. The lion populations are greatly going
down while the wild dogs have become extinct.
The Serengeti and the Maasai Mara are world popular for their
wonderfully exceptional population of wildlife-including a
yearly migration of approximately two million wildebeest.
The Mara itself was voted recently as one of the Seven Wonders
of the World. But during the near past many species of animals
have been threatened by severe droughts, more intense grazing
by the Maasai communities and increased poaching. The ILRI
between 1989 and 2003 carried out a monthly count of the 7-
ungulate species – the hartebeest, giraffe, impala, zebra,

7. warthog, waterbuck and Topi. The results depicted a decline in
their populations especially in hartebeest and warthogs. These
trends have been supported by separate different aerial count of
the game animals that was done between 1979 and 20002 by the
Kenyan government resource sensing and department of
resource surveys. By the year 2002 the giraffe population had
fallen in the reserve by about 20% of the levels that there was in
1979, the bulk of these losses did occur in the year 1989.
Hartebeest and Topi fell to about less than half in relation to
their population in 1979 and almost disappeared in the
ranchlands that are in the neighborhood where they used to
graze.
The number of impalas declined by about 70% in Mara alone
while that of warthogs fell by more than 80 percent despite
appearing steady since 1989.
Erosion of the habitat
The game loses were greatly pronounced in the regions where
the populations of human settlements had risen, even after
factoring out the impact of drought. Wildlife had been reported
to be constantly moving between the ranchlands and the reserve
and they were reportedly increasingly competing with livestock
for habitat (Campbell and Borner,1995). Particularly more
human settlements in the ranchlands are grazing their livestock
in the reserve which is an illegal activity the Maasai community
resort to when stricken with prolonged drought. This intrusion
causes a steady erosion of the game habitat therefore leading to
the observed declines. By the time the survey was ending in
2002, the populations of human settlement and agriculture have
continued to increase and human activity like grazing on the
game have soared greatly , so the declines are more likely to be
accelerated. The Maasai settlements in the right circumstances
can actually benefit the game grazers populations, the

8. researchers found. The researchers sated that human settlement
can act as safe havens by repelling predators away as a result of
human activities. The traditional Maasai who depended mostly
on livestock and who never consumed wild animals, helped to
maintain the abundance of the grazers in the region, and this has
continued to help the grazers in places where it is practiced,
though the growing pastoralist communities and their exclusion
from the formulation of land policies have made it impossible to
maintain their traditional way of life.
In the past few decades, most Maasai have left their homesteads
composed of mud walled and grass thatched houses to more
permanent houses a huge number of which have now crowded
the ranchlands bordering the park. With increase in these
permanent human settlements, the abundance of wildlife went
down significantly. The scientists at ILRI are helping to
promote schemes where the human communities that live near
the park are given rent payments from privately owned lodges in
return for allowing the game animals to continue to wander on
their property.
The loss of habitats
This remains one of the main wildlife threats globally. In East
Africa, the decline of wildebeest migration is as a result of land
use activities including land subdivision, cultivation, fencing,
settlements that disrupt the movement of the migration and
cause the population of wildebeest to decline drastically
(Bedelian,2012).
Fences
They interfere with migratory routes and cause deleterious
effect to the population of wildlife. Fences are used as a means
of stopping the disease transmission and resource competition
between livestock and wildlife, to protect homes, prevent
poaching and to protect crops. Fences are however known to

9. disrupt migratory routes thereby decreasing wildlife
populations. More than 20% of the Mara ecosystem has been
fenced and several migratory routes that link the game reserves
have been blocked (Kideghesho et al.,2006).
Roads
Roads obstruct migratory routes. They cause deaths of wildlife
due to vehicle collusion and decrease the connectivity of
landscape (Fyumagwa,2013) . Due increased access road
networks are capable of opening up new developmental areas
leading to the incompatibility of land use with wildlife (Dobson
et al,2010).
Solution
s to the threats
Investing in evidence-based solutions
We know that for many years in history, pastoral livestock
keeping has co-existed with the renowned concentration of
game animals of East Africa. This therefore means that policy
makers should look to these pastoralists to obtain solution to the
current problems. With the help of local communities and the
significant revenues coming from tourism, investing in
evidence-based approaches that can protect the iconic wildlife
population as well as the pastoral communities (Duerksen &

10. Snyder, 2013). Since most migrant stroll outside the protected
zones, it is important that the local communities as well as the
landowners be included in conservation programs, in benefit
sharing and in the management of wildlife. In the range lands of
east Africa, the economic benefits from wildlife to local
communities has been meager with limited incentive to initiate
migrant protection programs, their migratory corridors or their
dispersal areas.
Efforts should be made to ensure that wildlife dispersal areas
are protected and migratory corridors kept safe and free from
human interference through the use of conservancies and
initiation of economic incentives (Estes, 2006).
Coming up with a solution to solve the water hazard
Africa has been particularly vulnerable to climatic change; the
ever-rising temperatures are capable of cutting crop yields by
more than 20 percent. In an ecosystem that is already depleted
and with poor infrastructure unable to handle a population that
is growing so fast, the region is in the brink of a bleak future.
The problems of water shortages go beyond the Savannah and
affect humans too (Ogutu et al.,2012). This shortage has made
the local communities to compete with wildlife for critical
resources. One of the best solutions to this is the creation of

11. irrigation systems and dams to deal with the situation when
drought comes.
Another viable solution to the threats is the formulation of
conservation policies, for example the conservation of the
migratory routes need the implementation of plans to conserve
protected boundary areas. Migratory corridors and dispersal
areas can be opened up for wildlife by encouraging land use that
is wild life friendly and the participation and cooperation of
private and community landowners. The correct enabling policy
and a conducive legislative environment should be provided by
governments to support conservation initiatives, because of the
trans- boundary nature of the wildebeest migration in the East
African region, the respective governments of the involved
countries should come together in a collaborative approach to
mitigate the threats that face the migration.
One way I can help save the migration
To save the migration I would participate in the gathering ad
provision of good scientific information regarding where, when
and why the migration of the wildlife occur to inform
management and conservation decisions. This would encompass
tracking and mapping the movements of the game animals, the
levels of the population, the ecological drivers of the population

12. and a better understanding of the threats to the migrants as well
as their habitats.
According to CSU 2013, the collaring of wildebeest as a means
of tracking their movement helps in making decisions about
how to secure their critical habitats. By participating in this,
there would be a proactive approach in place anticipating to
respond to the crisis since scientific data would be in place to
help make informed decisions.
This initiative is likely to inform decision making and policy
formulation in conservation measures. If this initiative is done
on a continuous basis there is the possibility that the migratory
routes as well as the critical habitats of the game animals will
be protected from the threats they are currently facing.
Data due to mapping
The below maps produced by and KWS, IFAW and SFS track
and map three different collared elephant bulls (called ESM,
MAM, and OSM).The mapping shows how the Selenkay
Conservancy has been used in the Eselenkei Ranch as part of
their extended rangeland far off the Amboseli National Park.
This shows how the animals have extended their range far off
the Park into their former areas of dispersal. Mapping shows the

13. movement of animals and the areas that they are therefore
calling for conservation purposes.
Pamphlet
The Serengeti ecosystem is a game reserve in Africa located in
northern Tanzania and extending into Kenya in the southwestern
parts. The reserve spans about 12000suqare miles. The Kenyan
section of the Serengeti reserve is called Maasai Mara.
The reserve hosts the biggest terrestrial mammal migration in
the whole world thereby securing it a slot in the list of the
seven natural wonders of the world yet again appearing in the
list of the ten natural travel wonders of the world.
The numbers of Warthog, giraffe, impala, hartebeest, and topi
fell by about 50% between the year 1979 and 2002. This decline
is linked to the rapid growth of human settlement around the
park according to a research done by the international livestock
research institute in published in a journal of zoology.
This situation does paint a bleak image and requires decisive
and urgent action if the treasure has to be saved from the
disaster. The loss of grazers is already creating an impact on the

14. lion population and the cheetahs. The carnivores are the first
casualties since they depend on this wildlife. The lion
populations are greatly going down while the wild dogs have
become extinct (Sinclaire et la., 2008).
The number of impalas declined by about 70% in Mara alone
while that of warthogs fell by more than 80 percent despite
appearing steady since 1989.Since this was a report conducted
in 2002, it can only be imagined how drastic the situation
currently is since the human settlements have continued to
increase over the years, this has also made their activities that
are not game friendly to increase to (Wilcove, &
Wikelski,2009).With such a situation at hand, I call upon the
individuals, the civil society, the private sector and donor to
come together and help save the world's greatest migration in
East Africa.
Source: Aerial survey by Department of Resource Surveys and
Remote Sensing (DRSRS).
livestock and livestock population trends in Masai Mara
Ecosystem, 1975–2007.
Source: Aerial survey by Department of Resource Surveys and
Remote Sensing (DRSRS).

15. Wildlife and livestock grazing together, there is stiff
competition forPastures due to increased overstocking in Masai
Mara
References
Bedelian, C. (2012). Conservation and Ecotourism on Privatised
Land in the Mara Kenya: The Case of Conservancy Land
Leases.
Campbell, K., & Borner, M. (1995). Population trends and
distribution of Serengeti herbivores: implications for
management. Serengeti II: dynamics, management, and
conservation of an ecosystem, 117-145.
Dobson, A. P., Borner, M., Sinclair, A. R., Hudson, P. J.,
Anderson, T. M., Bigurube, G., ... & Estes, A. B. (2010). Road
will ruin Serengeti. Nature, 467(7313), 272-273.
Estes, R. D. (2006). Wildebeests of the Serengeti. Natural
History, 115(7), 28-35.
Duerksen, C., & Snyder, C. (2013). Nature-friendly
communities: habitat protection and land use planning. Island
Press.
Fyumagwa, R., Gereta, E., Hassan, S., Kideghesho, J. R., Kohi,
E. M., Keyyu, J., ... & Nyahongo, J. W. (2013). Roads as a
threat to the Serengeti ecosystem. Conservation Biology, 27(5),

16. 1122-1125.
Harris, G., Thirgood, S., Hopcraft, J. G. C., Cromsigt, J. P., &
Berger, J. (2009). Global decline in aggregated migrations of
large terrestrial mammals. Endangered Species Research, 7(1),
55-76.
Kahurananga, J., & Silkiluwasha, F. (1997). The migration of
zebra and wildebeest between Tarangire National Park and
Simanjiro Plains, northern Tanzania, in 1972 and recent trends.
African Journal of Ecology, 35(3), 179-185.
Kideghesho, J. R., Nyahongo, J. W., Hassan, S. N., Tarimo, T.
C., & Mbije, N. E. (2006). Factors and ecological impacts of
wildlife habitat destruction in the Serengeti ecosystem in
northern Tanzania. African Journal of Environmental
Assessment and Management, 11, 17-32.
Kideghesho, J. R., Røskaft, E., Kaltenborn, B. P., & Tarimo, T.
M. (2005). 'Serengeti shall not die': Can the ambition be
sustained?. The International Journal of Biodiversity Science
and Management, 1(3), 150-166.
Ogutu, J. O., Owen-Smith, N., Piepho, H. P., Kuloba, B., &
Edebe, J. (2012). Dynamics of ungulates in relation to climatic
and land use changes in an insularized African savanna
ecosystem. Biodiversity and Conservation, 21(4), 1033-1053.

17. Sinclair, A. R. E., Hopcraft, J. G. C., Olff, H., Mduma, S. A.,
Galvin, K. A., & Sharam, G. J. (2008). Historical and future
changes to the Serengeti ecosystem. Serengeti III: Human
impacts on ecosystem dynamics, 7-46.
Wilcove, D. S., & Wikelski, M. (2008). Going, going, gone: is
animal migration disappearing. PLoS biology, 6(7), e188.
Despite an established incident reporting system, Medcare
Hospital employees were simply not record-
ing medication errors in 2013. In fact, only two medication
errors were documented between January
and September of that year. Either staff was being incredibly
diligent in avoiding errors, or a lack of
proper data collection meant the hospital’s quality management
department (QMD) was not receiving
the full picture, and thus patient safety improvement efforts
were not being fully supported. This criti-
cal question needed to be answered.
About Medcare Hospital
Medcare Hospital is a 64-bed private general medical facility in

18. the United Arab Emirates city of
Dubai. Opened in 2007, Medcare employs 577 full-time staff,
the hospital has an emergency depart-
ment, 25 outpatient consultation rooms, an intensive care unit, a
neonatal intensive care unit, delivery
suites, an endoscopy room, and a day-surgery unit. The
hospital’s QMD was one of the first established
in the company to support quality improvement and patient
safety functions.
Discovering Unreported Errors
Errors involving patient medication can happen various ways,
many creating potentially life-threaten-
ing scenarios. If a hospital employee dispenses the wrong
medication due to an illegibly written order,
or if a nurse gives a medication to the wrong patient, the
ramifications can be deadly. Not only does
the patient suffer, but the hospital could face legal action and
the staff member who made the error
could have his/her career derailed as a result. Therefore, when
Medcare’s QMD staff learned only two
medication errors were reported during the first nine months of
2013—a new low mark for the depart-
ment after reported errors had been decreasing in recent years—

19. management determined it imperative
to identify what barriers or struggles existed for employees to
reporting errors through the existing sys-
tem, and what, if any, changes needed to be made.
Given these circumstances, an improvement project focused on
medication error reporting was a good
fit for the QMD performance improvement program. The
program is based on data collection and
statistical analysis to evaluate performance, measure outcomes,
identify improvement opportunities,
and determine priorities. Medcare’s performance improvement
activities are prioritized in collabora-
tion with the facility’s administrative and clinical leadership. In
this case, hospital leaders understood
unreported errors could compromise patient safety and inhibit
efforts to improve safety results. “Error
detection is the first crucial step,” said Shaheena Surani,
assistant quality coordinator at Medcare
Hospital. “In order to build safer systems, we must be able to
learn from previous errors. Reporting
discloses medication errors, can trigger warnings, and
encourages the diffusion of safe practice.”
Making the Case for Quality

20. Lack of Reported Medication
Errors Spurs Hospital to Improve
Data Focus, Patient Safety
• A quality improvement
project at Medcare Hospital
centered on unreported
medication errors.
• A cross-functional team
used the FOCUS-PDCA
model to determine
root causes and identify
potential improvements.
• Upon implementing
a variety of low-cost
solutions, staff members
felt more comfortable
in reporting errors,
thus providing valuable
information for building
safer systems.

21. At a Glance . . .
by Janet Jacobsen
June 2015
ASQ www.asq.org Page 1 of 5
www.asq.org
Establishing the Project Team
With permission from CEO Ala Atari,
Medcare leadership created an improve-
ment team to pursue the issue in October
2013. Team members were selected based
on their involvement in the error reporting
process. Additional members from man-
agement were also chosen so they’d be
informed of, and involved with, the effort,
Surani said. Members of the improvement
team included:
• Anu Augustian, head of the pharmacy

22. department
• Abdul Kareem, chief pharmacist
• Elizabeth Schulze, chief nursing
officer
• Khairunnisa Shallwani, education
and training coordinator, quality
department
• Shaheena Surani, infection control
coordinator, quality department
• Haitham Naeem, head of the
emergency room
• Rejimol Benny, head of general
ward two
• Dr. Ammar Hassan, general
practitioner
• Bincy Kurian, senior executive,
human resources

23. The nine-member team employed a vari-
ation of the plan, do, check, act (PDCA)
model known as FOCUS PDCA, which
includes the following process improve-
ment steps:
• Find the opportunity for improvement
• Organize a team
• Clarify the current process
• Understand or uncover/verify the
root causes
• Select the solution(s)
Clarifying the Process,
Uncovering Root Causes
Having identified the improvement
opportunity and with its project team
assembled, the group’s first task was to
clarify the error reporting process as it
exists, and can be seen in Figure 1.
ASQ www.asq.org Page 2 of 5

24. Incident
occurred
File
closed
Action
taken
Action
taken
Concerned
department
to close case
Tabulation
and data
analysis
Immediate
action required
Opportunity for

25. improvement
Further
action required
Medication
error
Form forwarded
to the supervisor
Form forwarded
to QMD
QMD for data
collection
Sent to concerned
committee
OVR �lled
(MCH-MF-012)
Forwarded
to pharmacy

26. for resolution
Improvement
planned for
implementation
YES
YES
NO
NO
NO
YES
YES
NO
Figure 1: Current Error Reporting Process

27. “Despite the existence of (an) inci-
dent reporting system, hospital staff
did not report most of the medication
errors that had occurred. Sources of
errors included: illegibly written orders,
dispensing errors, calculation errors,
monitoring errors, and administration
errors, e.g., giving the wrong medication
www.asq.org
ASQ www.asq.org Page 3 of 5
to the patient,” said Khairunnisa Shallwani, quality and train-
ing coordinator at Medcare. Given these sources, the project
team concluded physicians, pharmacists, and nurses can all be
involved in medication errors.
The team then used brainstorming sessions to identify pos-
sible reasons for inconsistent error reporting. Once determined,
the reasons were plotted on a fishbone diagram, as shown in
Figure 2. The causes were divided into four categories: policy,
people, process, and plant (work environment). Under these cat-

28. egories, various potential reasons were noted, including: fear of
punishment for reporting an error, lack of hospital policy
aware-
ness, increased workloads, insufficient procedures, an absence
of feedback, and regular audits.
Once the reasons for failing to report medication errors were
detailed, the team interviewed doctors, nurses, and pharmacists,
while also using observation to collect data through gemba
walks
to confirm or refute the list of suspected root causes. Based on
the data collected, the team detailed 14 potential root causes:
• Increased workload
• Fear of punishment
• Fear of consequences
• No regular feedback from pharmacy employees
• Error not considered a reportable error
• No pharmacy audit
• Lack of process orientation
• Low self-esteem
• Lack of policy awareness
• Lack of interest to report
• No risk management program

29. • No system in place
• No department head reinforcement
• Lack of awareness for medical error reporting
The Pareto diagram in Figure 3 illustrates the number of
responses for each of the 14 potential root causes.
Developing and Selecting