PDSA Cycle for Reducing Medication Clinical Incidents in Healthcare

This report delves into the application of the Plan, Do, Study, Act (PDSA) improvement cycle to address and mitigate medication clinical incidents within healthcare settings. The report emphasizes the importance of a structured approach to prevent errors, enhance performance, and improve patient safety. It outlines the four stages of the PDSA cycle: Planning, where healthcare professionals formulate objectives and strategies; Doing, where the plan is implemented on a small scale to gather data; Studying, where data is analyzed to assess the effectiveness of the interventions; and Acting, where modifications are made based on the study's findings. The report highlights how the PDSA cycle can be a powerful tool for healthcare institutions to accelerate quality improvement and reduce the likelihood of adverse events. The report also provides insights into the roles of nurses in each stage of the PDSA cycle, emphasizing the continuous improvement process to eliminate medication errors.

MEDICATION
CLINICAL INCIDENTS

Abstract
In order to prevent medication clinical incidents, it is important for healthcare professionals to
make appropriate plan, implement the plan, monitor the activities and determining the
modifications required to make improvements. PDSA improvement cycle is prepared by health
care institutions which is considered as a powerful tool for accelerating quality improvement.
Change is necessary in the clinical institutes in order to enhance the performance and reduces the
incidents. Plan Do Study Act (PDSA) cycle to underpin a report on medication clinical incidents
frequently carried out by nurses. The first stage of PDSA improvement cycle is Planning. Here,
the health care professionals creates a precise plan in which they determine what they want to
accomplish and how will they bring change in their practices. Once the aim, objectives and goals
has been formulated by the nurses, they have to work to gather data, record problems and address
issues as the evaluation progress. Study stage is most crucial stage which tells planner whether
the changes gives fruitful results or not. After analysing the data efficiently, the planner will
demonstrate the outcome favourableness.

Table of Contents
INTRODUCTION...........................................................................................................................1
PDSA improvement cycle................................................................................................................1
Plan..............................................................................................................................................1
Do................................................................................................................................................2
Study...........................................................................................................................................3
Act...............................................................................................................................................4
CONCLUSION................................................................................................................................5
REFERENCES................................................................................................................................7

INTRODUCTION
Incidents in patient safety typically arise amidst several possible contributing factors and,
without appropriate problem-solving strategies, can be exceedingly difficult to assess.
Medication clinical incidents can be occurred either due to carelessness of health care
professional, practitioner, nurses or patients (Knudsen and et.al., 2018). In order to prevent these
errors, it is important for healthcare professionals to make appropriate plan, implement the plan,
monitor the activities and determining the modifications required to make improvements. Using
process improvement models such as PDSA (Plan, Do, Study, Act) significantly improves the
likelihood of determining, addressing, and correcting key errors that lead to negative occurrences
(Knudsen and et.al., 2018). In this context, the report will aid in comprehending the concepts of
PDSA process through which health care professionals can eliminates the errors that leads to
medication clinical incidents.
PDSA improvement cycle
Chartier and et.al., (2017) enunciated that PDSA improvement cycle is prepared by health care
institutions which is considered as a powerful tool for accelerating quality improvement. Change
is necessary in the clinical institutes in order to enhance the performance and reduces the
incidents. To test the changes and evaluating the benefits and limitations from changes, PDSA
improvement cycle tool has been used by the organisation.
Plan
According to Reed and Card, (2016) an incident is any event or circumstances that led to
unintended or unexpected harm, loss or damage. At certain times while providing medication to
the patient, health care professionals or medics made unintentional mistake which leads to harm
and damage to patient. These incidents impact on the patient health and might lead to more
severe damages. Leis and Shojania, 2016 said that in order to eliminate the errors in medication,
it is important for health care professionals to make appropriate plan which specify what he or
she is trying to accomplish, how will he or she know that change is an improvement and what
change can be made that will result in improvement. The first stage of PDSA improvement cycle
is Planning (Cartwright and et.al., 2017).
Here, the health care professionals creates a precise plan in which they determine what
they want to accomplish and how will they bring change in their practices. Medication clinical
incidents can be seen in health care institutes and these incidents negatively impacts on health of
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patient or health care seekers. Patient safety is a major concern in healthcare systems worldwide
and it is essential for management of health care organisations to provide excellent care to the
patients (Curatolo and et.al., 2015). According to Brown and et.al., (2017) to test the changes
implemented by the health care organisation, nurse have to follow certain steps. The first step is
to state the objectives of test. In this step the nurses prepare the objectives of the test where they
anticipate what will happen and why it will happen. In next step, nurses develop a plan to test
change (Byrne, Xu and Carr, 2015). In this they determined what role will be played by whom
in order to reduce the chances of errors and incidents during process of medication. For example,
nurses desire to reduce the possibilities of medication clinical incidents to 40 per cent than they
have to set the objectives accordingly, develop a plan in which they will determine what kind of
role will be played by whom so that desired objectives of change can be accomplish effectively
and efficiently (Calderwood, Mahoney and Jacobson, 2015).
Planning is the first stage in PDSA improvement cycle in order to test the impacts of
change it is crucial for the nurses to prepare precise plan so that errors in medication can be
eradicated effectively and efficiently. Planning is the preliminary process of implementing the
changes in the organisation (Tsang and et.al., 2017). According to Calderwood, Mahoney and
Jacobson, 2015 to reduce the errors in future, an individual has to make appropriate plan. Here
nurses have to create objectives, make questions and predictions and establish a plan to carry out
the improvement cycle.
Do
According to Puri and Spevetz, (2018) this is the second stage in Plan Do Study and Act
(PDSA) cycle of improvement. Once the aim, objectives and goals has been formulated by the
nurses, they have to work to gather data, record problems and address issues as the evaluation
progress. In short, they have to carry out the test on small scale. Kresch, Kurtz, and Lubin,
(2017) elucidated that in order to examine and evaluate the plan prepared in the first stage, it is
important for the planners to implement it in at small scale level to collect data regarding the
changes. This can help nurses to document the data and examine it in precise manner.
They can evaluate the collected data in precise manner and check the benefits and
limitations of the changes that has been made by them in order to reduce medication clinical
incidents (Hatch and et.al., 2016). For example, nurses can start with one clinician at one
afternoon during medication process and later on increases the number after they refine the ideas
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(Studeny and et.al., 2017). After gathering the relevant data, they can proceed further to analyse
it. Medication clinical incidents have adverse impact on the health of patient. Subramanyam,
Buck, and Varughese, 2016 said that PDSA is often used in the education sector as a cycle for
continuous improvement when implementing a strategy, intervention or possible solution to a
problem.
PDSA is an excellent tool for any organization to create a continuous cycle of learning &
improvement. To eliminate the errors in medication and to improve the quality of care in
healthcare organisation, it is essential for nurses to make changes that can simplify their work
and eradicated the possibilities of medication incidents (Guinto and et.al., 2016). In this stage the
nurses at small scale level implement the desired plan to test the changes and record the data in
order to analyse it appropriately.
The PDSA tool is user friendly. It serves as a standard template to showcase the tests that
we have done, highlight the success we have achieved and spread the works to a larger scale.
The whole stage is meant to provide justification whether the desired change is going on as per
the plan or not (Knudsen and et.al., 2018). If it is not going as per the plan then nurses needs to
redevelop the plan according to the change needed and implement it in precise manner so that
both plan and changes can be aligned with each other efficiently. Burke and Shojania, 2018
argued that nurses needs to carefully monitor the process and make precise analysis so that
evaluation can be made. Collection of information is essential criteria. Here the nurses have to
monitor and make communication with fellow workers in order to gather required data from
them regarding the changes.
Study
Sadasivaiah and et.al., (2017) said that Study is the third stage in Plan Do Study and Act
improvement cycle. This is most crucial stage which tells planner whether the changes gives
fruitful results or not. Here, the nurses inquired the drafted statement of plan prepared in first
stage and gathered data from the second stage in a way which helps them to determine at what
margin the plan was resulted in an improvement. This stage is crucial for nurses where nurses
evaluate all the impacts of the change and its side effects. According to Headrick, Paull and
Weiss, (2017) study stage in improvement cycle is further classified into certain stages. In first
stage of study, the nurses as to make analysis of the gathered data. This is done in order to obtain
meaningful information regarding the changes.
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Data analysis is essential as it assist in transforming raw data into meaningful
information. Data has been collected through survey or observation by nurses and they analyse it
in order to generate resourceful outcome from it (Knudsen and et.al., 2018). It will tell the clear
position of what affects the changes and what else can be done in order to reduce the adverse
effects. In next stage, the nurse has to compare the data from the anticipation they have made in
the planning stage. This is done in order to ensure whether the data has been matched with the
predictions made or not. If it is made than nurses will proceed further and if it has not matched
than nurses has to redevelop the plan and implement it so that it can be aligned with predictions
effectively and efficiently (Chartier and et.al., 2017). In the last stage, nurses have to summarise
the analysis and reflect upon what has been learned during the whole process.
Slight and Bates, (2016) said that in order to implement the changes in the organisation it
is essential for the management of the company to make plan, make small scale investigation and
analyse the data collected from the investigation thoroughly so that evaluation of the changes can
be made and modifications can be made eventually. Medication clinical incidents can be
devastating as it can damage the health of patients (Reed and Card, 2016). Medication incidents
can not be ignored and in order to eradicate those errors, it is important for the healthcare
institutions to make effective changes within the organisation so that medication clinical
incidents can be reduced. Nicolay and et.al., (2012) argued that in order to reduce the medication
clinical incidents and ensure the safety of patient it is necessary for the management of
healthcare institutions to make plan, implement it and observe the benefits and limitations of the
changes made.
Act
Robarts and et.al., (2008) elucidated that this is the last stage of PDSA improvement cycle where
the management reflect on the results. After analysing the data efficiently, the planner will
demonstrate the outcome favourableness (Leis and Shojania, 2016). If the outcome are
favourable, then the plan can be implemented in the system and if plan fails to bring the
necessary improvements, the planner has to pick up the pieces and begin again at the planning
stage. Here, the nurses have to reflect on the results acquired from the analysis of data.
Determine what modifications should be made and prepare a plan for next test (Walley and
Gowland, 2004). In order to eradicate the issue of medication clinical incidents and errors it is
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essential for nurses to prepare a specific plan, create anticipations, implement the plan at small
scale level, collect data, analyse collected information and reflect on the results acquired.
This is the whole process of PDSA (Plan Do Study and Act) improvement cycle, through
which nurses can bring the change in the institution that can obliterate the medication incident
and errors effectively and efficiently (Calderwood, Mahoney and Jacobson, 2015). Act is the last
stage of the process where nurses identifies the area of modification and rectifications and
determine the process of next cycle. In this stage the nurses check whether the changes aid in
reducing the errors or not (Cartwright and et.al., 2017). They identify what areas were majorly
affected from the changes and what issues stems out from the changes. In order to eliminate
those issues, nurses will make another plan and follows the same steps from the beginning.
PDSA cycle helps in testing the change implemented in the health care institution by the nurses
(Brown and et.al., 2017). As the motive of healthcare institutions is to provide effective and
efficient care to the patient so that they can have excellent experience. In order to ensure the
safety of patient it is important for healthcare institutions to incorporate changes to eliminate the
issue of medication clinical incidents. Healthcare institutions are encompasses with countless of
specialised process, equipment, medicines and methodologies including vast network of
institution and suppliers (Byrne, Xu and Carr, 2015).
In its broad boundaries, a healthcare organisation involved healthcare professionals,
pharmaceuticals, nurses, software developers and myriad other individuals and groups all with
their own method, ethical standards and reasoning (Calderwood, Mahoney and Jacobson, 2015).
The main purpose of all the people involved in the healthcare organisation is to not to harm, to
ensure the safety of patient and other workers. By implementing model such as PDSA, the
management of healthcare organisation might be able to enhance patient safety protocols and
continue to foster the basic ideal of human safety preservation.
CONCLUSION
In the above report, the explanation of PDSA improvement cycle has been provided for
reducing the medication clinical incident in the healthcare organisation. PDSA improvement
cycle is prepared by health care institutions which is considered as a powerful tool for
accelerating quality improvement. Change is necessary in the clinical institutes in order to
enhance the performance and reduces the incidents. To test the changes and evaluating the
benefits and limitations from changes, PDSA improvement cycle tool has been used by the
5

organisation. The first stage of cycle was planning. In this stage nurses have to prepare
objectives, establishing anticipation and plan for data collection. The second stage of the model
is implementing the plan at small scale level. Here, nurses have to collect the data by using
survey and observation. In the third stage, nurses have to analyse the collected data and compare
it with the predictions. This is most important stage of the process. The fourth and last stage is
act, where nurses reflects on the results. In this way, the whole process will aid in implementing
the change within the healthcare institution.
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REFERENCES
Books and Journals
Brown, P. C., & et.al. (2017). Abstract TP383: Use of Plan-Do-Study-Act and Clinical
Simulation Methodology to Develop a Mobile Prehospital Telestroke System.
Burke, R. E., & Shojania, K. G. (2018). Rigorous evaluations of evolving interventions: can we
have our cake and eat it too?.
Byrne, J., Xu, G., & Carr, S. (2015). Developing an intervention to prevent acute kidney injury:
using the Plan, Do, Study, Act (PDSA) service improvement approach. Journal of renal
care, 41(1), 3-8.
Calderwood, A. H., Mahoney, E. M., & Jacobson, B. C. (2015). Sa1462 A “Plan-Do-Study-
Act”(PDSA) Approach to Improving Bowel Preparation Quality. Gastrointestinal
Endoscopy, 81(5), AB225-AB226.
Cartwright, L., & et.al. (2017). Use of Plan Do Study Act Cycle to Enhance Timely Care for
Patients Presenting to Emergency Department for Cardiac Implantable Device
Interrogation. Heart, Lung and Circulation, 26, S282.
Chartier, L. B., & et.al. (2017). Quality improvement primer part 2: executing a quality
improvement project in the emergency department. Canadian Journal of Emergency
Medicine, 1-7.
Curatolo, N., & et.al. (2015). Reducing medication errors at admission: 3 cycles to implement,
improve and sustain medication reconciliation. International journal of clinical
pharmacy, 37(1), 113-120.
Guinto, L. B., & et.al. (2016). Poster 495 Patient Experience in an Outpatient Pain Clinic: A
Plan-Do-Study-Act Quality Improvement Project. PM&R, 8(9), S321.
Hatch, L. D., & et.al. (2016). Interventions to improve patient safety during intubation in the
neonatal intensive care unit. Pediatrics, e20160069.
Headrick, L. A., Paull, D. E., & Weiss, K. B. (2017). Patient quality safety of care and. A
Practical Guide for Medical Teachers, 215.
Knudsen, S. V., & et.al. (2018). Can Quality Improvement improve the Quality of Care? A
systematic review of effects and methodological rigor of the Plan-Do-Study-Act (PDSA)
method. Bmj Quality and Safety.
Knudsen, S. V., & et.al. (2018). Does Quality Improvement improve the Quality of Care? A
Systematic Review of the Effect and Methodological Rigor of the Plan-Do-Study-Act
(PDSA) Method.
Kresch, M. J., Kurtz, M., & Lubin, J. (2017). Improving handover between the transport team
and neonatal intensive care unit staff in neonatal transports using the plan-do-study-act
tool. Journal of neonatal-perinatal medicine, 10(3), 301-306.
Leis, J. A., & Shojania, K. G. (2016). A primer on PDSA: executing plan–do–study–act cycles in
practice, not just in name. BMJ Qual Saf, bmjqs-2016.
Nicolay, C. R., & et.al. (2012). Systematic review of the application of quality improvement
methodologies from the manufacturing industry to surgical healthcare. British Journal of
Surgery, 99(3), 324-335.
Puri, N., & Spevetz, A. (2018). QUALITY ASSURANCE AND PATIENT SAFETY IN THE
INTENSIVE CARE UNIT. Critical Care Secrets E-Book, 71.
Reed, J. E., & Card, A. J. (2016). The problem with plan-do-study-act cycles. BMJ Qual Saf,
bmjqs-2015.
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Robarts, S., & et.al. (2008). A framework for the development and implementation of an
advanced practice role for physiotherapists that improves access and quality of care for
patients. Healthcare Quarterly (Toronto, Ont.), 11(2), 67-75.
Sadasivaiah, S., & et.al. (2017). Improving best possible medication history with vulnerable
patients at an urban safety net academic hospital using pharmacy technicians. BMJ Open
Qual, 6(2), e000102.
Slight, S. P., & Bates, D. W. (2016). Fundamental Approaches to Measuring and Improving
Patient Safety. America's Healthcare Transformation: Strategies and Innovations, 31.
Studeny, S., & et.al. (2017). Quality improvement regarding handoff. SAGE open medicine, 5,
2050312117729098.
Subramanyam, R., Buck, D., & Varughese, A. (2016). Infusion medication error reduction by
two-person verification: a quality improvement initiative. Pediatrics, 138(6), e20154413.
Tsang, L. F., & et.al. (2017). Using the PDSA Cycle for the Evaluation of Pointing and Calling
Implementation to Reduce the Rate of High-Alert Medication Administration Incidents in
the United Christian Hospital of Hong Kong, China. Journal of Patient Safety & Quality
Improvement, 5(3), 577-583.
Walley, P., & Gowland, B. (2004). Completing the circle: from PD to PDSA. International
Journal of Health Care Quality Assurance, 17(6), 349-358.
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