Transcript Document

Title: Medication Error Process Improvement Plan
Scope/Boundaries: Collection of data relevant to PSW med errors.
Review data to eliminate non PSW medication errors. Define what a
medication error will be. Complete a root cause analysis on all relevant
errors. Develop strategies, inc education/training for PSW’s.
Team
Executive Sponsor: Maggie Mercer
Team Lead/Process Owner: Tiziana Pelusi
Improvement Advisor: JoAnn Zomer, Steve Kavanagh,
Pharmacy task force
PROBLEM STATEMENT: Current statistics shows that agency wide, PSL has
on average 2-4 medication errors per month. Client satisfaction survey
indicates lower satisfaction levels related to PSW knowledge and training
on mediation practice. As a result, clients health and well being are
negatively impacted, as is the trust relationship between PSW and
Client.
Team Members: Tiziana Pelusi, Jing Hong, Joeann
Shorey, Kenisha Morales, Vanessa Young, TBD:
Daniela Popivici
Aim Statement: Decrease the number of medication
errors made by PSL PSW’s by 50% over the next 12
months.
Measures:
Outcome measures: reduction of medication errors by 50%.
Process Measures: Pilot small group of clients receiving medication
assistance. Provide PSW’s with additional education and training on
medication process and reporting techniques. Develop specific
questions on client satisfaction survey that will target medication
management by PSW.
Balancing Measures: - Reduction of medication errors, increased client
satisfaction with PSW medication knowledge. - Discovery of Med errors
that do not get properly reported. -Increasing reporting will increase
average number of medication reporting errors.
Root Causes of the Problem: Identified through
adverse event reports and client satisfaction survey
. Data shows that PSL on average experienced 2-4
PSW med errors a month, and clients requesting
more PSW training on assistance with medication.
Change Ideas:
Education and training, closer monitoring of medication process, specific
training with contacted agency staff and relief PSW’s, incorporate UCP
training agency wide. Incorporate strategies to achieve 100% reporting
of adverse events for med related events.
Relationship to root cause and Change idea of training and education of
staff which is reflected on the data base.

Anticipated Timeline: Project starts December 2014 and ends November
Anticipated Barriers and Mitigation Strategies:
Title: Project Title
Scope/Boundaries: Indicate the beginning and end steps and the process
being focused on
Team List the names and positions for:
Executive Sponsor (someone on senior management who will be
accountable at a senior level, will remove barriers, ensure adequate
resources are provided, etc)
Team Lead (Person accountable for accountable for leadership of the
project team and accountable for day-to-day project progress)
Process Owner (often the unit manager or person in a management
position accountable for the process being improved; this person often
acts in the position of Team Lead)
Improvement Advisor (Someone who does not necessarily have content
expertise, but provides and builds QI expertise in the team; if the Process
Owner is not the Team Lead, the IA may act in the position of Team Lead)
Team Members (based on the SIPOC, ensure individuals from the front
line who are most familiar with the process are included, and where
possible, “suppliers” and “customers” who may be impacted through
inputs to or outputs from the process
Aim Statement:
Articulate your project aim stating “How much” (amount of improvement
– eg 30%) , “by when” (a month and year), “as measured by” (a big dot
indicator or a general description of the indicator(s)) and/or “target
population” (eg COPD patients)
Root Causes of the Problem:
How were they identified?
Include any available evidence.
Change Ideas:
What are they?
What is the hypothesized relationship between the root causes and the
change ideas?
Is there evidence in the literature or elsewhere for the relationship?
Anticipated Barriers and Mitigation Strategies:
Anticipated Timeline
Over how many months will the project be conducted? If possible, specify
start date by month and year, and end date by month and year
Problem Statement:
. What is the problem and what parts of the organization does it
impact/touch?
. Why is this important to the organization? Is it linked to a strategic
priority?
. Is there data or other evidence that helps to highlight the problem?
Measures:
Include a Family of Measures:
. Outcome Measures
. Process Measures
. Balancing Measures
Key Milestones: Identify key points over the project duration at which
time you anticipate key deliverables/results
Resources Required:
Budget, Dedicated Staff Time (if necessary for senior management to
know, especially if the dedicated time is significant) For example, if you
require the team to be available a half day every week, a process owner to
spend 20% of his/her time, back-fill for front line staff, etc
Signatures: Signals that these individuals have read the Charter and are
aware of the project focus, and at minimum, commit to and agree with the
design, set up, and resource requirements at the early stages.
Executive Sponsor: _______________________________
Process Owner: __________________________________