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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.
Other________________________________________________________________________