during ta1, your team will…

TA1: REVIEWING THE SCENARIO & THE DATA

During TA1, your team will…• Review the provider agency scenario • Review and learn from the distributed data set• Identify and report on any gaps in the data

Activity Aids2. Provider Agency Scenario3. Medication Errors data set

Directions & Reporting• Individually and then as a group, review and discuss the data • Document your group’s work and transfer it to the whiteboard to report out on:

• Share your team name• What you learned from your data and what are the gaps (what would be helpful to find out?)

• QM tools and process used to reach consensus

This activity should take about 45 minutes, followed by an additional 15 minutes for reporting out.

Activity Aid #2

ODP QUALITY MANAGEMENT CERTIFICATION Provider Agency Scenario

ODP has created a scenario to help class participants work toward creating a mock Quality Management (QM) Plan and accompanying Action Plan.

During this class, we will use ABC Agency as our example and Medication Administration Errors (MAEs) data as the focus of our QM Plan and Action Plan.

SCENARIO: ABC AGENCY

This agency has served ODP programs for 10 years. They are mostly focused on Residential Habilitation (RH). The agency’s headquarters and all 20 of its RH service locations are based in Allegheny County. At these 20 locations, they have the capacity to serve 100 individuals.

Over the previous 2 years, ABC Agency has noticed some troubling trends in terms of MAEs. They have decided to develop a QM Plan and Action Plan with a goal of identifying the types of MAEs that are occurring most frequently and acting to reduce MEs in all categories.

The following staff structure pertains to our mock agency.

ABC AGENCY STAFF NAME and/or TITLE Ed Douglas, Executive Director Quinn Marks, Quality Manager Maria Duca, Medical Director Colin Nash, Charge Nurse RH House Supervisors RH House Staff

DEFINITION: MEDICATION ADMINISTRATION ERRORS

From 55 Pa. Code § 6000.923: Any nonconforming practice with the "Rights of Medication Administration" as described in the OMR Medication Administration Training Course. This includes omission, wrong dose, wrong time, wrong person, wrong medication, wrong route, wrong position, wrong technique/method and wrong form. Over the counter medication is excluded. … A medication error occurring during a home visit, when the family is responsible for the administration, is not reportable. An individual's refusal to take medication is not reportable.

ODP Quality Management Certification ‐ August 2020

Activity Aid #3


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ODP QM Certification ~ Medication Errors Data

ABC Provider by Secondary Incident Categories

SFY 16‐17

SFY 17‐18

Jul '16

Aug '16

Sep '16

Oct '16

Nov '16

Dec '16

Jan '17

Feb '17

Mar '17

Apr '17

May '17

Jun '17

Jul '17

Aug '17

Sep '17

Oct '17

Nov '17

Dec '17

Jan '18

Feb '18

Mar '18

Apr '18

May '18

Jun '18

Omission 109 146 11 11 18 8 11 7 5 6 0 12 8 8 6 15 8 16 17 5 12 3 17 8 24 15

Wrong Dose 40 46 4 7 2 2 3 4 0 2 4 3 6 3 3 6 1 2 4 3 3 2 6 4 8 4

Wrong Form 2 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Extra Dose 4 7 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 2 1 0 3

Med DC'd 6 0 0 1 0 1 1 0 0 0 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 Wrong Reason 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0

Wrong Person 2 5 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 1 1 0 1 1 1 0 0 Wrong Position 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Wrong Route 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Wrong Method 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Wrong Time 13 5 1 2 4 0 0 0 1 1 1 3 0 0 2 0 0 0 2 0 0 0 0 0 1 0

Total 177 210 17 21 24 11 15 11 6 11 11 20 17 13 12 21 9 18 24 10 15 6 26 14 33 22

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during ta1, your team will…

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