University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet
Department____Neuro ICU________ Date___10.2014_____
Primary Contact Person___David Ornelas RN, BSN_ Extension 85490
(F) Find a Process to Improve (name the process, describe the beginning and ending steps in
the process, name the customers served; state why it is important to work on this now).
Opportunity Statement
After reviewing data provided by the units nurse educator and Kaizen committee meeting,
it was evident our documentation of override medications and proper handoff of high alert
drips needed improvement. There were multiple safety intelligence reports filed due to
medication errors related to improper handoff. Also, pharmacy audits of override
medications revealed an alarmingly high incidence of undocumented medications. My
goal is to educate staff on how to properly document and the importance of medication
safety for the patient. Moreover, I aim to decrease need for use of override function and
decrease safety intelligence reports on medication errors related to improper handoff.

Circle all that apply:

Dimension of Performance: Dimensions of health care performance are those definable,
preferably measurable, attributes of the system that are related to its functioning to maintain,
restore, or improve health care.
- Efficiency
- Safety
- Staff Satisfaction
- Effectiveness
- Patient Centeredness
- Continuity
Prioritization:
- High Risk
- High Volume
- Problem Prone
- Low Volume

High Impact on Performance

High Potential for Improvement
Supports Critical Success Factors
Patient Safety

Other________________________________________________________________________

(O) Organize a team that knows the process:

List Team Members:
David Ornelas, Angela Dangler, PharmD, Krystal Chamberlain, Christine Steckline
_____________________________________________________________________________
(C) Clarify the current knowledge
What do we know about the process?
Current evidence clearly states independent double checks, when used correctly, increase
patient safety and decrease potential for human error. Literature also indicates a 15% potential
for medication error when override function utilized incorrectly. Based on pre-education audits
and conversation, staff are unsure of proper route to document appropriately. The need for
education is apparent.
_____________________________________________________________________________

(U) Understand sources of variation:

Why are we looking at this process? Why is the process not going the way planned?
Proper medication administration and documentation increases patient safety and outcome.
Safety intelligence reports indicated a need to revisit our practice in the Neuro ICU.
_____________________________________________________________________________
(S) Select the improvement:
My goal is to educate staff on not only how to properly document override medications but also
the appropriate times to utilize this function. Also, create a culture change in the unit to make
independent double checks of high alert medications second nature.
_____________________________________________________________________________
(P) Plan the improvement:
I plan to develop a power point presentation highlighting the components and steps to properly
document and the importance it plays in patient safety. This and a poster board will be presented
to staff at monthly staff meetings and available for each shift in our huddle room. Individual
instruction will be done when warranted as well.
____________________________________________________________________________
(D) Implement the improvement:
1. Present education in two ways to educate all Neuro ICU nurses.
2. Foster culture change through implementation of shift to shift checklist.
_____________________________________________________________________________
(C) Check the results:
Post education audits show a marked increase in compliance of independent double checks and
correct documentation of override medications.
_____________________________________________________________________________
(A) Act to hold the gain:
I plan to continue audits and educate accordingly. As part of new staff orientation to the unit, I will
educate and illustrate importance of patient safety. I will continue to track safety intelligence
reports related to medication errors.
_____________________________________________________________________________

Repeat PDCA as needed and maintain documentation in your department.