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Preventing Medication Errors : A nurse's journey using QI tools .By Neetu Taneja

I always wanted to do something to improve the quality of health care ever since I attended the QI workshop on 6th and 7th May 2017.

The quality of care is severely compromised in public health care sectors which are contributed by lack of infrastructure and inadequate manpower.

But after attending QI workshop I realized that how we can bring big changes with few simple and small ideas which is possible with the existing manpower and infrastructure. The only thing which is essential for improvement is the focused approach, perseverance and right attitude.

My journey begins in August 2017, when I noticed that during transcribing daily treatment from patient’s case sheets to nurse’s treatment book identification details of the patient are not entered properly. With this there are sure chances that patient’s identity could be misinterpreted and wrong treatment could be given.

I wanted to ensure that there is no harm to my patients from insufficient identification details in the treatment register.

I have realized from my past experiences that I was not able to do much and my efforts were not sufficient enough to bring any change ever.

Better late than never I happened to attend the QI workshop organized by QI Cell, KSCH and NQOCN India. This 2 day workshop showed me a ray of hope in bringing changes of improvement. It was like a dream come true to me. I realized how I wasted my energy and time by putting on my efforts to bring about quality improvement. During these 2 days best thing I learned was how to move from “I” to “WE”.

I went back to my department with new wine in old bottle. I had already identified the problem but since I wanted to replace “ I” with “we” we formed a team, made an aim statement and our work has started.

Apart from team members every body refused to write identification details in the treatment register initially saying that it was surely going to increase their workload.

According to QI strategies this part is anticipated from colleagues. So we team members remained calm and never blamed any of our colleagues for not participating in the QI work.

Our 1st change idea was to develop a right attitude among nurses involved. So we tried to sensitize the need for identification details in the treatment register. This message spread by word of mouth. This was our 1st PDSA. Spreading the need by word of mouth. Some started entering the details, some ignored and some got angry.

We did not abandon the first PDSA and 2nd PDSA started by using a red pen it was written on top of every page that “ Plz enter the patients name along with fathers name and CR No.”

Very few people still preferred to ignore this request. For them we added one more PDSA that was to display pictorial diagrams of children saying “Plz mention my name with my fathers name and CR No. It will help you to identify me correctly and easily. I am sure you will do it for me.”

Some rigid minds started melting with this dialogue with picture.

Now there is a significant improvement in the percentage of names with sufficient identification details ie Father name and CR No. in the treatment book.

Still there are one or two nurses who are determined not to go with improvement in Quality of care. When they are not on duty our result is 100%. There will be a time that seeing all others they will also start entering the patient details in the register.

No… this is not the end.QI workshop taught us to celebrate the success.

So we celebrated our success during our tea break with sandwiches and coffee in the dept. and cheering each other!!!

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1 Comment

Sushil Srivastava
Sushil Srivastava
Aug 18, 2020

Preventing medication errors as a project work highlights valuable learnings for all quality improvement enthusiast.

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