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9 Using the QI essentials toolkit to assess risk, drive and sustain improvement in medication safety
  1. Mouna Ayoub Bahsoun,
  2. Anya Neidig
  1. Intermountain Primary Children’s Hospital


Background Barcode-assisted medication administration (BCMA) is an evidence based practice to reduce medication administration errors; however, compliance rates with the use of this technology sometimes vary between different healthcare workers. Improving BCMA compliance benefits healthcare organizations in their efforts towards Zero Harm.

Objectives Achieve less than 2% BCMA overrides at a pediatric hospital, within a 12 months’ timeframe.

Methods To improve BCMA adherence across all disciplines, the IHI’s QI Essentials Toolkit was used to guide an interprofessional team of nurses, physicians, pharmacists, respiratory therapists, imaging techs and quality professionals. The team came together to conduct a Failure Mode and Effects Analysis (FMEA) and identify units with overrides rates above 2% to build a task force (figure 3). A nurse manager was identified as the task force leader and every unit was represented by a leader and a worker at the point of care. The task force prioritized addressing knowledge, attitudes and behaviors towards BCMA and applied change concepts to engage the workforce in using the technology. This priority was backed up by availability of weekly data that allowed drilling down to individual measurement of medications administered and BCMA use. Continuous improvement was tracked through run charts that displayed organizational and unit-level results starting with pre-interventions baseline data.

Results A sustained BCMA overrides rate below 2% was achieved, with a mean of 1.26 (figures 1 and 2).

Abstract 9 Figure 1

Hospital-wide medication overrides

Abstract 9 Figure 2

Imaging – medication overrides

Abstract 9 Figure 3

Primary children’s hospital - failure mode and effect

Conclusions When introducing an interprofessional team to proactive risk assessment and continuous improvement, the IHI’s QI Essentials Toolkit proved effective in providing the team with tools to prioritize efforts, test change, achieve results and sustain improvement over time, all while supporting organizational learning.

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