Protocol Development and Quality Improvement

Objective: Critical care pharmacists should participate in developing ICU and institutional policies, procedures,

guidelines, and education.

Policy – A course or plan of action; written policies establish standards of practice or quality/compliance

measures and protects against error. Policies intend to show the “why” behind an action and include

a description of “what,” “when,” “who,” or “where” actions should occur in a specific situation. Most

policies are mandatory and may result in disciplinary action if not followed. Policy is based on well-

defined standards including those that may be required to comply with laws, regulations, or contracts.

Benefits

Improves consistency and efficiency of work processes

ii.

Provides a training tool during a new employee’s orientation

iii.

Provides reference material for education and practice

iv.

Minimizes practice variations

Reduces the organizational risk by mandating compliance

Development and implementation should involve all relevant team members to ensure all concerns

are addressed and to promote input from all stakeholders.

Examples of policies:

Acute pulmonary embolism response team

ii.

High-alert medication list and safety standards

iii.

Pharmacist initiated automatic therapeutic interchange

iv.

Pharmacist-initiated intravenous to oral conversion

achieve a desired result or accomplish a task in a consistent manner; the “how” to achieve the desired

outcome or comply with a stated policy.

Requires approval by the organizational committee

Describes each team member’s responsibility

Defines the expected outcome(s)

Written instructions

ii.

Flowcharts

iii.

Checklists

Can be used as a QI tool or a source of measures

Examples of procedures:

Central line placement

ii.

Medication event reporting

iii.

Use of the AddEase Administration System

iv.

Downtime procedures during system outages or natural disasters

clinical circumstances. Should include all aspects of care including the following: Patients that are excluded

from the treatment or have contraindications, initiation criteria, dosing (if applicable), titration, monitoring,

education, duration of therapy, etc.

Supports clinical decision-making by defining best practice

Developed by examining the evidence and gaining consensus among practitioners