The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). Late one busy afternoon a pharmacy received a call from a carer to say that a patient had received not only their own medication but also that of another patient. Soon after another carer called to say their patient had not received their medication. The driver had delivered the medication earlier that day. After speaking to the driver it transpired that: • The driver was a temporary driver and this was his first day working in the area • Both patients had similar addresses, one living in 8 Smith Ave, the other 8 Smith Rd. • The patient who received the medication could not remember receiving two different packages. She was elderly and confused. • It was not unusual for more than one package to be delivered to the same address The immediate conclusion of the team was that the error was the result of the inexperience of the driver and no further action was necessary. However, a more detailed review of the incident highlighted: • That the driver was not aware of the SOP and had not been accompanied on a trial run prior to the day of the incident • The delivery log allowed the signature of the person receiving the medication to be recorded, but not the number of packages received. • The dispensary team were aware that two patients had an almost identical address, but failed to highlight this to the driver • Neither the dispensary team nor the delivery log highlighted where more than one patient was living at the same address. • The driver did not highlight to the pharmacist at the end of his run that a patient listed on the delivery log did not receive any medication The next stage of the review involved using the PDSA tool. Plan To carry out a full risk assessment of the delivery SOPs, including accompanying the driver on his run Do To amend and implement the revised SOPs to minimise risk, based on the issues identified Study To review the findings. Aap jaisa koi meri zindagi mein aaye hindi song download. Were your objectives met? Act To identify any further changes In this particular case a second action, to carry out a risk assessment of the current use of the Near Miss / Dispensing Error log, led to a relaunch of the Near Miss / Dispensing Error Log with all staff and a more robust analysis of incidents, involving the entire team, resulted. This example illustrate how two different tools designed to support safe systems of working, if used properly, facilitate safer practice and also help the pharmacy team to demonstrate that they proactively identify and minimise risk to their patients. This is particularly relevant in light of the new inspection visits by GPhC. It is also important to note that all SOPs should be reviewed at least every two years and that a risk assessment of each SOP should be carried out. The ‘Model For Improvement’ promoted by Quality Improvement Hub Scotland introduces three fundamental questions: • What are we trying to accomplish? • How will we know a change is an improvement? ![]() ![]() • What changes can we make that will result in improvement? These questions are a starting point for reviewing any aspect of practice and, along with PDSA cycle, form the basis of the Model for Improvement. Diablo cam wifi cccam anleitung schneeflocker. Carol Watt Locum Pharmacist. Background The necessity for quality and safety improvement initiatives permeates health care., Quality health care is defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (p. According to the Institute of Medicine (IOM) report, To Err Is Human, the majority of medical errors result from faulty systems and processes, not individuals.
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