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Module 4 • Quality & Safety
Protocol Development & Quality Improvement
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Protocol Development & Quality Improvement
Jaime Robenolt Gray ~3 min read Module 4 of 20
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Protocol Development and Quality Improvement

12The Choosing Wisely initiative of the American Board of Internal Medicine Foundation was a

collaboration of critical care societies including the American Association of Critical Care Nurses,

American College of Chest Physicians, American Thoracic Society, and Society of Critical Care

Medicine. The goal was to drive conversations between clinicians and patients about what procedures,

tests, and treatments are truly needed. The 11-year campaign ended in 2023. The Choosing Wisely

campaign identified many examples; however, these are now encouraged to be emphasized through

specialty societies for publication of these lists. The campaign website still emphasizes the following

for patient advocacy to ask questions of their care team:

Do I really need this test/procedure?

What are the risks?

Are there simpler, safer options?

d.What happens if I don’t do anything?

How much does it cost?

Patient Case

3

You are reviewing compliance with the national patient safety goals in the perioperative setting specific to

appropriate medication labeling. Through observation, you notice that there are inconsistencies in how pro-

pofol is drawn up and labled in the syringe, if labeled at all. In the majority of cases, the name of the drug is

placed on the label. What other information should be included on the label of the syringe?

A.Patient name, drug name, dose, and expiration date/time.
B.Drug name, concentration, diluent if applicable, and expiration date/time.
C.Patient name, drug name, drug dose, and concentration.
D.Drug name, drug dose, concentration, and diluent if applicable.
D.The goal of the ASHP Practice Advancement Initiative (PAI) is to significantly advance the health of patients

by supporting futuristic practice models that support the most effective use of pharmacists as direct patient

care providers. The initiative aims to assist leaders and practitioners in creating a framework, determining

services, identifying emerging technology, developing templates, and implementing change. The ASHP

Pharmacy Practice Model Initiative started in 2010. See Figure 1 for the Practice Advancement Initiative

2030 recommendations.

E.Local Quality Initiatives (from ASHP: The ASHP Discussion Guide on the Pharmacist’s Role in Quality

Improvement)

1

Every accredited hospital must participate in QI initiatives.

2The overall goals of the PI programs are to maintain and support the delivery of safe, quality care.
3

Each program should include the following:

Adherence to standards of care

Opportunities for improvement, with action plans to implement change strategies

Strategies for the effectiveness of change strategies

d.Involvement of multidisciplinary teams in process improvement
4

PI plans should:

Articulate the commitment to PI

Delineate the goals of the PI process

Specify the authority and responsibilities for PI

d.Describe the organizational structure and process related to the PI program

Describe the method for improving organizational performance

Describe the communication and recognition of PI activities

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