Al Sypniewski, CEO

David N. Greenhaw, MD

Janeen Pharr, PharmD, Director of Pharmacy

Judy Ramey, BSN, CNO

Linda Chaffin, RHIT, Director of Quality Improvement

Barry Yearber, CRT, CPFT, Director of Respiratory Services

Brandi Taylor, RN, Nurse Manager Medical/Surgical and Critical Care Unit

Richie Arnold, RN, Nurse Manager Emergency Department

Nora Chambers, RN, Nurse Manager, Geropsychiatric Unit

Cathy Killough, RN, Infection Control Practitioner

Teresa Barrett, RN, Education Director

• To improve patient safety cultures by 50 percent
• To decrease the number of ADEs per 1,000 doses by at least 50 percent
• To improve percent of unreconciled medications by 50 percent
• To decrease FMEA score by 50 percent

• ADEs per 1,000 doses
• FMEA Score
• Medication Reconciliation at Admission and Discharge
• Patient Safety Culture

• Implemented reconciliation process at admission and discharge
• Implemented Safety Culture Walk-Rounds with feedback to staff of actions taken on safety issues
• Implemented Safety Briefings at shift change
• Involved patient and family in medication safety through education
• Adopted “do not use” abbreviation list
• Conduct safety culture surveys every 6 months
• Adopted high-risk medication list and implemented double checks for high-risk medication
• Established renal dosing guidelines
• Eliminated concentrated electrolytes from floor stock
• Implemented laser MAR to automatically print at 2200
• Implemented chronological profile to automatically print at 2200
• Implemented read back policy
• Incorporated staff education in orientation and annually
• Implemented Hot Line for reporting MSVs
• Re-enforced non-punitive environment to improve reporting of MSVs
• Implemented reward system for reporting MSVs
• Implemented two patient identifiers
• Implemented weekly Patient Safety Impact meetings
• Initiated Weight Based Heparin Protocol
• Initiated standing orders for Pneumonia, COPD and AMI
• Store “look alike” “sound alike” drugs away from each other in pharmacy and on nursing units
• Implemented “look alike” “sound alike” alerts on medications for MARs
• Implemented standing order for baseline levels on patients on Warfarin, dioxin and Theophylline
• Initiated double check of Insulin validated on MAR by two nurse signatures
• Reduced floor stock in ED through a physician initiated formulary reduction to prevent ADE
• Initiated double check for potassium
• Implemented allergy alert armband

• Have fun
• Gain administrative support and involvement
• Gain medical staff support and involvement
• Build interdisciplinary oversight team
• Involve staff directly involved in the process
• Involve the patient and family in medication process
• Improve safety awareness through safety briefings and walk rounds
• Communicate successes with staff and medical staff
• Use Rapid Cycles of Change
• Educate patients and staff
• Keep processes simple

Linda Chaffin, RHIT
Director of Quality Improvement