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QUALITY IMPROVEMENT
USING
FOCUS-PDCA MODEL

PHARMACY DEPARTMENT
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FIND OPPORTUNITY FOR

IMPROVEMENT
Jan Feb Mar Apr May Jun Jul Aug Sep
Medication Error 0 1 0 0 0 1 0 0 0
 Organize a Team
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Anu Augustian HOD- Pharmacy

Abdul Kareem Chief Pharmacist
Elizabeth Schulze Chief Nursing Officer

Khairunnisa Shallwani Education and Training
Coordinator/ Quality Dept.

Shaheena Surani Infection Control
Coordinator/ Quality Dept.

Haitham Naeem HOD- ER

Rejimol Benny HOD- General Ward 2

Dr. Ammar Hassan General Practitioner
Bincy Kurian Senior Executive- HR
 Clarify the current process
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 Uncover the Root Causes
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The Quality Improvement Team

identified many possible reasons
through brain storming which is
plotted using a fish bone model.
FISHBONE DIAGRAM USED TO
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IDENTIFY ROOT CAUSES

 Root Cause Verification
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To confirm the reasons and collect

data the following techniques are
used:

-Personal Interview
- Observation
 Uncover/Verify Root
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Causes
OCCURRENCE
No of
Cumulat
SL No Reasons Respons %
ive %
es
1 Increase workload 29 15.76 15.76
2 Fear of punishment 27 14.67 30.43
3 Fear of consequences 26 14.13 44.56
4 No regular feedback by pharmacy 24 13.04 57.6
5 Error not considered as error to report 18 9.78 67.38
6 No audit by pharmacy 14 7.61 74.99
7 No orientation regarding the process 12 6.52 81.51
8 Low self esteem 9 4.89 86.49
9 Unaware of policy 5 2.72 89.21
10 Lack of interest to report 5 2.72 91.93
11 No risk Management program 5 2.72 94.65
 Uncover/Verify Root
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Causes
OCCURRENCE
No of
Cumulat
SL No Reasons Respons %
ive %
es
12 No system in place 5 2.72 97.37
13 No reinforcement by HOD 3 1.63 99
Lack of awareness for Medical Error
14 2 1 100
reporting
TOTAL 184
 Pareto Diagram Used to Verify
Root Causes
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 Select The Improvement Using The Solution
Selection Matrix
Cost. is it Total
11 cost Leadershi Practical Acceptan Is time Scor
effective ? p support? ? ce effectiv e
Proposed Solutions 20 25 15 20 e ? 20 900
1. Ensure appropriate staffing 80 125 90 100 120 515
2. Train for Managing Time effectively 80 125 105 100 120 530
3. Ensure mix skill staff assignments to all units 100 50 150 100 120 520
4. Plan staff leaves ahead of time for Annual 120 200 150 100 120 690
5. Have a planner for leaves 120 200 150 100 120 690
6. Provide assuring and correct information
regarding the process 140 150 90 100 140 620
7. Reduce the extent of punishments 160 200 120 160 140 780
8. Provide continues education as per hospital
policies and procedures 140 150 90 100 140 620
9. Share the medication error cases within unit
staff meetings 80 125 105 100 120 530
10. Encourage Medical Error reporting with
positive feedback and less consequences 140 150 90 100 140 620
11. Plan monthly audit schedule for each unit 120 200 150 100 120 690
12. Provide monthly data to all unit heads
regarding Medication error 140 150 90 100 140 620
13. Pharmacy must release quarterly action plan
for the audit results 120 200 150 100 120 690
14. Spot checking by pharmacy for the proper
medication usage process. 80 100 60 80 100 420
15. Offer medication safety session to all new
staff and a refresher after 3 months 160 200 120 160 140 780
16. HOD will review Medication error and its
types with staff as an ongoing process. 140 150 90 100 140 620
 Select The Improvement Using The Solution
Selection Matrix
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Cost. is it Leadershi Is time

cost p Acceptan effective Total
effective support? Practical? ce ? Score
Proposed Solutions ? 20 25 15 20 20 900
17. Empower staff by timely and updated
education regarding medication
administration and medication safety 120 200 150 100 120 690
18. Provide Channels to ventilate their
anxieties and fears 140 150 90 100 140 620
19. HOD works as an advocate for her staff
and provide support as required. 120 200 150 100 120 690
 Plan the Improvement
Date of
13 Areas of Responsible
Sl No Plan Cost Completio
improvement Person
n
Fear of Reduce the extent
1 CNO/ HOD/HR Nil Nov. 2013
Punishment of punishments
Offer medication
Safety session to all
Error not
new staff and a Pharmacy AED
considered as Ongoing
2 refresher after 3 Educator 1000
error to report/ Nov. 2013
months HOD
No orientation
OVR process flow to
all units
HR
Plan staff leaves
Increase CNO Nov. 2013
3 ahead of time: Nil
workload HOD ongoing
Annual
Duty Managers
No regular
Plan monthly audit Nov 2013
feedback by Pharmacy
4 schedule for each Nil ongoing
pharmacy/ less HOD
unit
frequent Audits
No regular Pharmacy must
Oct, 2013
feedback by release quarterly
5 Pharmacy NIL ongoing
pharmacy/ less action plan for the
frequent Audit audit results
 Plan the Improvement
14 Date of
Areas of Responsible
Sl No Plan Cost Completio
improvement Person
n
Empower staff by
timely and updated
Educator
education regarding NOV 2013
6 Low self esteem HOD Nil
medication On going
CNO
administration and
medication safety
HOD works as an
advocate for her HOD Nov. 2013
7 Low self esteem Nil
staff and provide CNO on going
support as required
Share the
medication error CNO
Fear of Nov. 2013
cases with in unit Educator
8 Punishment/ on going
staff meetings and Pharmacy Nil
Consequences
during Medication HR
safety sessions
Fear of Provide continuous
Educator Nov. 2013
Punishment/ education as per
9 HOD Nil on going
Consequences hospital policies and
HR
procedures
 Plan the Improvement
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Date of
Areas of Responsible
Sl No Plan Cost Completio
improvement Person
n
Spot checking by
pharmacy for the
Less frequent proper medication
Audit / No usage process Quality Dept. Dec. 2013
11 Nil
regular feedback Provide monthly Pharmacy ongoing
by Pharmacy data to all unit
heads regarding
Medication Error
HOD will review
Error not
medication error
considered as HOD Dec. 2013
12 and its types with Nil
error to report/ Duty Managers ongoing
staff as an on going
No orientation
process
Provide channels to HOD
Dec. 2013
13 Low self esteem ventilate their CNO Nil
ongoing
anxieties and fears Duty Managers
HR
Increase Train for managing
14 Educator Nil Nov. 2013
workload Time Effectively
HOD
 Plan the Improvement
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Date of
Areas of Responsible
Sl No Plan Cost Completio
improvement Person
n
Share the
Fear of HOD
medication error Nov. 2013
15 Punishment/ HR Nil
cases within unit Ongoing
Consequences CNO
staff meetings
Ensure mix skill CNO
Increase Nov 2013
16 staff assignments in HR Nil
workload
all units HOD
Ensure appropriate
Nov 2013
staffing CNO
Increase Introduce training HR
17 Nil
workload for staffing plan as HOD
2014
per unit Educator
Planner
requirement
Encourage staff to
verbalize their
issues of reporting
18 Low self esteem HOD Nil Nov 2013
Head nurse
encourage staff to
report
 Do
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Some Planned Solutions were

implemented over a period of two
months and the others are on going.
 Check did it works?
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Medication Error Report

BEFORE AFTER
 Improvement Noticed
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Medication error reporting has been

increased
Support system is available for staff to
ventilate their feeling
Audit schedule planned
Sharing of medication error report on
quarterly bases
Action plan by pharmacy was shared and
will be done on regular bases
 Act: Maintain the Gain
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Ongoing education
Support system for staff to share
their fears and anxiety
Staff is aware of different types of
medication errors and knows how to
report: noted during session.
Audits & reports by pharmacy
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THANK YOU!!!