Delaware success stories

DE Success StoriesQuality improvement endeavors can often feel overwhelming, but chances are, you can learn from the experiences that another physician, hospital or nursing home has had in a similar situation. Coupled with support from Quality Insights Quality Innovation Network, learning what has worked for others — and what didn't — is a valuable strategic planning component. 

We encourage you to read the success stories, contact us for more information, and also let us know if you have a Quality Insights' success story to share.

Nanticoke Memorial Hospital Uses Data to Combat Anticoagulant Medication Events

When Quality Insights tasked the facilities in its Reducing Adverse Drug Events (ADE) project with identifying an area for improvement, Nanticoke Memorial Hospital in Seaford, DE thought it knew exactly what to work on. “We originally chose to work on the opioid ADEs but discovered after looking at some of our data that we had more anticoagulation medication events,” said Jean Conn, Patient Safety Officer. Thus began a truly data-driven quality improvement project to reduce anticoagulation medication events and improve patient safety at the hospital. 
Nanticoke has worked with Quality Insights for many years, so it was an easy decision to attend the kick-off meeting for the medication safety project in September 2014. After that, staff hit the ground running, armed with new tools and data collection devices provided by its Quality Insights project coordinator, Jami Jones. In July 2015, Nanticoke arrived at two different tools to be used at the facility to collect data on anticoagulation medication events.

“In the beginning we had to work with our IT department and do some revisions to our reports before we were confident they were giving us what we needed from the electronic medical record,” said Conn. Staff also worked closely with Quality Insights to ensure that the data that was being collected was providing information that could be used to affect change and improve care. In the end, Nanticoke’s diligence and attention to detail paid off.

Results from the facility’s data collection revealed deficits in patient education in relation to anticoagulant prescribing. Not only were patients not being educated on anticoagulant use consistently while in the hospital, but upon discharge, they were handed a paper with a vague directive to “see your physician within the next week.”

Once these discoveries were brought to light, process change began. Now, patients are discharged with an actual follow-up appointment with their primary care physician (PCP) already on their calendar. Education on anticoagulant use happens with every patient, and Nanticoke staff now reviews their data monthly to ensure nothing slips through the cracks.

To back up their anticoagulant medication event prevention efforts, Nanticoke instituted staff education on anticoagulants and the definitions of adverse medication events, a review of event reporting and reminders about the availability of the adverse drug reaction (ADR) hotline. The facility also created an adverse drug event committee, which was originally all leadership but is currently being transitioned to include front-line staff.

Nanticoke staff will continue to educate where needed to improve medication error reporting. They will also continue to stress the importance of making an actual appointment with the PCP for the patient, which encourages the patient to attend the important visit. 

“This was a good learning experience on developing data collection tools and really honing in on defining what the data is you need to effect change,” commented Conn.