Abstract PS1-44: Using Fault Tree Analysis and Probabilistic Risk Assessment to Improve Medication Safety in Ambulatory Care

T. S. Field, L. Garber, K. Chysna, B. Harrow, J. Tjia, J. H. Gurwitz
2008 Clinical Medicine & Research  
CM&R 2008 : 3/4 (December) 140 HMORN 2008 -Poster Presentations culture. Conclusions: Based on the results, our recommendations for increasing TRIP are: (1) ensure integrated development of a master data warehouse; (2) improve communication with special emphasis on involving researchers more directly with DS teams; (3) promote further research to identify what works/does not work in implementing TRIP; and (4) 'think globally, but translate locally.' Funded by NIH/AHRQ for the HMORN CCSN
more » ... ated Clinical Studies Network). Abstract PS1-41 Background: In reviewing first quarter clinical quality metrics in 2006, the primary care department at the Merrill Center identified a statistically significant drop in glycemic control for their diabetic population that did not occur across the clinic system-wide. Quality improvement changes were implemented from mid 2006 through mid 2007. Aim: To increase glycemic control more than 50% over 12 months as evidenced by the percentage of patients with diabetes having most recent A1c test results <7%. Methods: The system-wide quality improvement initiative increased provider awareness and educated providers on the need to improve clinical outcomes for patients with diabetes. Providers partnering with nurse educators resulted in increased referrals to the Diabetes Self Management program. Diabetes educators intensified insulin dosing for patients with uncontrolled blood sugars through use of a standard protocol. In addition to expanding existing diabetes services and hours, telephonic care management was initiated for high risk patients. Implementation: An electronic medical record (EMR) and tablet computers improved the information that providers and other members of the care team could use to access at the point of service. An electronic reminder system helps identify patients not at goal requiring further testing, education, or medical intervention. A process for gathering outside A1c test results improved the coordination of diabetes care across health care facilities. Results: Glycemic control as evidenced by the percentage of patients with most recent A1c test results <7% rose from 41% in second quarter of 2006 to 68.2% in third quarter of 2007 for the more than 800 patients with diabetes. Conclusions: To improve quality of care, provider awareness and support are essential in developing a comprehensive diabetes program. Increased provider awareness, supported by an EMR has built a team approach to education, medical management, and care coordination resulting in improved glycemic control. Abstract PS1-42 Demonstrating the Effective Practice Background: For 160 years, government agencies, corporations, and nonprofit organizations have relied on demonstrations of radical innovations and interventions to stimulate interest in them and subsequent diffusion. Unfortunately, researchers and practitioners alike often fail to distinguish the functions that a demonstration project may serve and, thus, put into practice hybrid demonstration forms that typically under-achieve in all functional objectives. Methods: We (1) visited internal demonstrations of effective practices in primary care, palliative care, and population preventive services, discussed the planning of demonstrations with national strategic support staff, and (3) reviewed the published literature about demonstration projects. Results: In Kaiser Permanente nationally, demonstration projects are often initiated without regard to functional specification, perceptions of potential adopters, communication training of demonstration staff, or knowledge of published literature about the operation of demonstration projects. Conclusions: The potential for improving the internal demonstration of effective practices in integrated healthcare delivery systems is large. Cost-effective strategies exist to improve the decision making of potential adopters, as well as accelerate the dissemination of effective practices through formative evaluation about the credibility of potential adopters, potential adopters' perceptions of practices to be demonstrated, staff training, and implementation support.
doi:10.3121/cmr.6.3-4.140-b fatcat:qnrryty5zvfgxggjx4pnixqwt4