Protocol Development and Quality Improvement
Strengths and limitations of evidence are described.
| d. | Health benefits, adverse effects, and risks are considered when developing recommendations. |
|---|
Link between recommendations and supporting evidence is provided.
Guideline is externally reviewed by experts.
Defined times for guideline updates are provided.
Clarity of recommendations
Recommendations are clear and unambiguous.
Different options are clearly presented.
If involving medication therapy, dosing is clear, including initial starting rate and titrations for
continuous infusions.
Applicability
Guideline describes facilitators and barriers to the application.
Guideline provides tools on how it should be applied to practice.
Guideline presents monitoring and/or auditing criteria.
Approval
Guidelines involving the use of medications should obtain appropriate committee-level approvals
prior to implementation.
Monitoring of adherence to the guidelines through MUEs to assess compliance or need for revisions.
All policies, procedures, guidelines/protocols should be accessible during periods of electronic health
system maintenance and downtime (planned and unplanned).
level are kept in a location where they can be easily accessed should a mass casualty event or downtime
occur
Patient Case
As the critical care pharmacist, you have been asked to develop a guideline for reversal agents used in the
setting of bleeding associated with anticoagulation therapy. Which is the best example of a component that
should be involved in establishing the clinical pathway?
and that is compared with a best practice model (actual vs. potential performance). Within pharmacy, a gap
analysis may focus on pharmacy services, pharmacy technology, or a specific medication or medication
process. A gap analysis can also be used to analyze gaps in processes and between the existing outcome and
the desired outcome. This process can be summarized as follows.