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

Learning Objectives

1

Determine the steps involved in the development of

a guideline and/or policy.

2Design a medication use evaluation (MUE) with

selection of an appropriate medication and/or medi-

cation-related process suitable for an MUE.

3

Determine the appropriate quality improvement tool

to use in order to optimize outcomes in a critically

ill patient population.

4

Identify processes or quality improvement initia-

tives that would benefit from a gap analysis.

5

Describe the types of pharmacotherapeutic inter-

ventions and documentation processes to justify the

value of clinical pharmacy services.

Abbreviations in This Chapter
ADE

Adverse drug event

ASHPAmerican Society of Health-System

Pharmacists

CMS

Centers for Medicare & Medicaid Services

CPOEComputerized provider order entry

CPS

Clinical pharmacy services

DUE

Drug use evaluation

EBM

Evidence-based medicine

EHR

Electronic health record

ICU

Intensive care unit

LOS

Length of stay

MUE

Medication use evaluation

PAI

Practice Advancement Initiative

PI

Performance improvement

P&T

Pharmacy and therapeutics (committee)

QA

Quality assurance

QI

Quality improvement

SUP

Stress ulcer prophylaxis

TJC

The Joint Commission

Self-Assessment Questions

Answers and explanations to these questions may be

found at the end of this chapter.

1

As the clinical coordinator/manager, you have

received a request to add the critical care pharma-

cist’s review of all intensive care unit (ICU) patients.

You recognize that you lack the necessary person-

nel to accomplish this request. Which justification

method would offer the most significant financial

impact on the institution to justify the position?

A.Developing protocols in the critically ill patient.
B.Reducing prescribing errors.
C.Reducing medication administration errors.
D.Implementation of an anticoagulation reversal

stewardship program.

2You are the critical care pharmacist implementing

a delirium screening tool in critically ill patients

according to the Society of Critical Care Medicine

guidelines. Which would best be described as a

practice environment barrier to implementing delir-

ium screening in your ICU?

A.The nursing standard work does not include

delirium screening.

B.Screening process takes up valuable nursing

time.

C.Providers are unfamiliar with how to perform

delirium screening.

D.Providers believe their knowledge of bedside

delirium is adequate and does not require a

screening tool.

3

The pharmacy and therapeutics (P&T) committee

would like to assess the use of pharmacotherapy in

stress ulcer prophylaxis (SUP) in the ICU. Which is

the best method for making this evaluation?

A.Perform a medication use evaluation (MUE).
B.Administer a performance improvement (PI)

initiative.

C.Review adverse drug event (ADE) data from

the ICU.

D.Review medication error data from the ICU.
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