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Quality Improvement Initiative Evaluation
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Introduction
In healthcare settings, plans for process-specific quality improvement are frequently
reactive and focused on actions to improve a single process. Harmful incidents or near-misses
will serve as a wake-up call for many healthcare organizations when patient well-being is a
priority, inspiring activities to enhance care. Quality improvement projects that concentrate
on particular issues must be carefully planned to elevate the level of care and expand patient
safety. The primary focus of this paper is the quality program implemented in the author’s
healthcare association to diminish pharmaceutical errors and improve healthcare safety. To
prevent pharmaceutical errors, interprofessional teams work together to pinpoint the root
causes of mistakes and implement preventative measures.
An examination of a contemporary QI project
Medication errors were common in the healthcare organization before initiating the
quality improvement (QI) program. Two mistakes that seriously hurt patients and were
exposed to the media caused the organization to face a lot of criticism. A QI program that
focuses on the issue of pharmaceutical errors was developed in response to these complaints
and the requirement to improve healthcare outcomes. Due to the high rates, a program was
established. Its primary goal was to address the causes of errors that were already occurring
to increase patient safety by reducing error rates.
The hospital board established a QI committee to begin a QI project in response to
medicinal errors. Clinical personnel, office employees, and QI coordinators made up the
interdisciplinary QI committee. Identifying the underlying causes of quality issues was the
first stage in testing, putting solutions into practice, and assessing the results. Although the
committee was established to provide a backing for overall quality, pharmaceutical errors
were its main area of interest. The Pharmaceutical Error Prioritization System (MEPS), a
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system for recording and categorizing drug errors within the healthcare system, was created
by the committee in response to medication errors. These two strategies summarize the
committee’s efforts to decrease pharmaceutical errors and improve patient safety.
Even though the effort generally reduced errors, doctors found it difficult to
implement. Many doctors chose to write traditional paper-based prescriptions instead of using
the convoluted and poorly developed e-prescription system. However, changes were made
that made the system easier to use. The QI program did not look into patient experiences and
how they affect the likelihood of drug errors. Patients did not immediately benefit from the
MEPS program because it is only available to staff, even though it improved reporting and
tracking. Due to fewer drug errors, the QI effort may not have improved patient safety as
successfully as it could have. The healthcare organization must make changes to increase user
access to the QI and gather patient experiences.
Analyze a current QI initiative’s performance.
The QI initiative was successful in part because fewer errors were made. Frequency
measurement is the primary yardstick for assessing quality improvement in pharmaceutical
mistakes. A 20% decrease in the reported number of medication errors was seen when
comparing medication error rates six months before and after the QI project was
implemented. Despite a trend in the right direction, it’s unclear whether reporting stayed the
same. Control for reporting rates is one of the main obstacles to evaluating the efficacy of
medication error reduction, according to Donaldson et al. (2017). Perhaps fewer practitioners
than in the past have reported medication errors. The QI initiative successfully lowered the
frequency of drug errors in the company, assuming that reporting remained consistent before
and after the effort.
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Second, the method lowered the percentage of pharmaceutical errors that led to both
temporary and severe injuries. The hospital divides errors that cause no harm, inconsequential
harm, severe harm, or death into three categories. Before the experiment, 30% of all reported
errors only resulted in temporary damage in 3% of cases and severe harm in only 1% of
cases. 90% of all issues had been resolved without putting patients in danger after the project
had been in place for six months. The effort improved patient safety overall by lowering the
percentage of errors that hurt patients. It is predicted that reporting rates will remain constant
before and after the program, just like the previous benchmark.
New metrics could be added to the existing metrics to assess the project’s success and
how effectively the technique was performed to increase patient safety. First, we must
ascertain the reporting rates. Practitioners must operate in a setting where reporting and
correcting errors is encouraged if the objective is to increase patient safety by minimizing
prescription errors (Morrison, Cope, & Murray, 2018). It must be a setting that encourages
higher reporting rates and is victim-free. It is necessary to have a system in place for
evaluating how well reporting is done within the company. Second, customer reviews would
benefit the business, particularly regarding how happy customers are with the healthcare
system. Patient happiness and experience with the healthcare system are closely related to
patient safety. To accurately assess the effectiveness of the QI effort, the organization must
incorporate metrics that measure patients’ views of safety and quality.
Perspectives from Various Professions
A multidisciplinary team worked on the QI project and contributed to this analysis.
Clinical staff, support workers, and QI coordinators were part of the interprofessional
strategy, which focused on particular and overall health improvement goals. Members of the
clinical staff, including doctors, nurses, and pharmacists, were the first category of
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professionals to be evaluated. The feedback was primarily concerned with users’ opinions of
usability and any issues they had with the QI effort. The rigidity and lengthy procedure of the
computerized prescription system, according to a nurse practitioner (NP), made it difficult to
utilize at first. However, she noted that with improvements and persistence from the
prescribing physician, the system minimized errors compared to paper-based prescription
methods. She stated that although MEPS accurately monitored errors, fewer medication
errors were not necessarily the result of its use. She also thanked the group for considering
clinical staff members’ perspectives and experiences when implementing the quality
initiative.
The e-prescription system has received overwhelmingly positive feedback from
support staff and QI coordinators for making identifying and eliminating drug mistakes
easier. The performance of information technology (IT) must live up to expectations, and
support employees are accountable for this. According to their perspective, effective
communication was essential for the initiative’s speedy implementation. The IT team utilized
the user interface improvements as an illustration to highlight the value of clinical staff
feedback in enhancing certain system functions. The QI coordinator also spoke about the
importance of fast feedback and communication while keeping track of pharmaceutical
errors. The QI coordinator says that encouraging reporting and fostering honesty is the most
challenging problem.
The interprofessional team’s observations revealed that the key issues were staff
reaction, motivation, and communication. The communication perspectives demonstrated that
the system was successful in boosting group efforts to lower pharmaceutical mistakes.
However, identifying problems with the reporting and e-prescription systems requires open
and timely communication. The healthcare organization recognized the pain in the
requirement for a strategy to promote more reporting and gauge reporting rates.
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Additional Protocols and Indicators
More indications, protocols, and technological advancements could help the QI effort.
The first suggested reform is implementing an anonymous reporting process that covers staff
and patients. It is a fundamental tenet of the healthcare system that all reports of drug
mistakes be made through a team. However, patients are also capable of identifying
pharmaceutical errors and the causes behind them. Morrison et al. (2018) emphasize the
significance of a non-punitive strategy for reporting medication errors to increase reporting
rates and safety in general. Journalists could avoid punishment for mistakes they find or make
by anonymous reporting. For instance, if a patient or nurse observes improper behavior that
could result in errors or safety concerns, they can report the incident confidently. The QI
committee can then take the appropriate action. The dependability of reports may degrade as
a result of this reporting method. This illustrates when a disgruntled employee makes
mistakes by criticizing their manager. The healthcare facility could utilize an anonymous
reporting method to encourage reporting of pharmaceutical errors despite the potential risk of
losing credibility.
Additionally, a drug reconciliation strategy based on patient records must be
implemented throughout the business. The pharmacist is typically in charge of reconciliation,
making sure the patient’s medication list is as current as practical. An interprofessional QI
team, however, will be involved in reviewing all patient records as part of an organization-
wide reconciliation effort and working with patients and their families to update medication
lists. Drug reconciliation has the advantage of using a collaborative method to find
discrepancies and interactions, boosting the accuracy of the prescription list and significantly
lowering the possibility of mistakes (Dufay et al., 2017). The assistance of clinical personnel,
patients, and their families must be enlisted to collect as much patient data as feasible. Patient
electronic health records (EHR) will be merged during the reconciliation process with
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assistance from the records manager and support staff to update and enhance the correctness
of the repository. Despite the procedure’s advantages, executing widely and maintaining
uniformity is challenging. Taking the process to encourage the correctness of current data into
account can help the QI effort be improved, regardless of how much time or money is spent
on reconciliation.
Conclusion
Medication error reduction necessitates coordinated efforts to overcome practice gaps,
as demonstrated in the healthcare organization. Medication errors commonly result in
fatalities in the healthcare system, which is detrimental to patient safety and the standard of
treatment. An increase in significant drug errors influenced the complex healthcare system,
which led to the creation of a QI project. MEPS and e-prescriptions helped to achieve the
goal, although more precise reporting and records may have been used. Throughout the
process, contributions from a range of staff members with various backgrounds are necessary.
This evaluation shows how improved reporting practices and reconciliation could benefit the
attempt to improve quality.
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References
Donaldson, L. J., Kelley, E. T., Dhingra-Kumar, N., Kieny, M. P., & Sheikh, A. (2017).
Medication without harm: WHO’s third global patient safety challenge. The
Lancet, 389(10080), 1680-1681. https://doi.org/10.1016/S0140-6736(17)31047-4
Dufay, É., Doerper, S., Michel, B., Marson, C. R., Grain, A., Liebbe, A. M., … & Alquier, I.
(2017). High 5s initiative: implementing medication reconciliation in France a five
years experimentation. Safety in Health, 3(1), 6. https://doi.org/10.1186/s40886-017-
0057-6
Morrison, M., Cope, V., & Murray, M. (2018). The underreporting of medication errors: A
retrospective and comparative root cause analysis in an acute mental health unit over
three years. International Journal of Mental Health Nursing, 27(6), 1719-1728.
https://doi.org/10.1111/inm.12475
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