This document outlines the Plan-Do-Study-Act (PDSA) process and provides an example of how it can be used to prevent medication errors. It defines the four steps of PDSA as: plan, do, study, act. As an example, a hospital used PDSA to decrease potential overdosing by requiring two nurses to double check all medication overrides after pharmacy hours and changing available dosages to match most common doses. They monitored errors related to overrides and made additional process changes based on the results.

1. Presented by: White River Medical Center
Robin Anderson BSN, Michelle Bishop MSN NEA, Valerie Ragsdell RN

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. 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. 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. Step 3: Study
 Examine your results
 Did the results match the theory/predictions
 Are there trends? Unintended side effects?
 Is there an improvement?

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. 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.  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.  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.  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.