Background It is commendable to improve routine processes. However, they have to be checked once implemented, to verify if they are being done properly. One way to do this is by performing an audit. When audits are performed and abnormalities are detected, an improvement plan must be established to prevent errors.
Purpose To evaluate the impact of an improvement plan (IP) in the database in the outpatient setting.
Material and methods A methodology of continuous quality improvement was applied following the Deming cycle (Plan, do, check and act). The audit was carried out in June 2013. Patients were selected who attended the pharmaceutical care outpatient consultation; belonging to several Hospital Units: General Clinical Nephrology (GCN), Renal Transplantation (RT) and Dialysis (D). These services were selected because their records are complex. These patients frequently shift from unit to unit. The general ATHOS-APD data were reviewed and checked against each patient’s medical record (paper/digital). An IP was developed based on the results of this audit.
The IP consisted of sending out the results of the review and holding a training session showing the professionals the correct way to keep patient records.
Six months later another audit was performed, to compare the results. Variables were collected: hospital unit, health area, type of patient (depending on the dispensed drug).
Results In both audits 26 patients were reviewed. In the first audit there were 9 patients (35%) in RT, 6 in GCN (26%) and 11 in D (42%). In the second, 5 in RT (19%), 8 in GCN (31%) and 13 in D (50%).
The records had 15% of errors in the first audit: 4 patients, 2 belonging to RT and 2 D who were registered in GCN. In the second, there was one error (4%): a patient belonging to D was recorded as in GCN.
The health area had a 19% errors in the first audit (5 patients). In the second no errors were detected.
The type of patient was wrongly recorded, in the first audit 4 patients (8%), and 2 (4%) in the second.
Conclusion The IP was successful. The first audit showed worse results than the second. Therefore using the Deming cycle enabled us to improve the quality of medical records.
References and/or acknowledgements No conflict of interest.
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