QAPI Program Utilization_Manual

PERFORMANCE IMPROVEMENT OUTCOME MONITORING Patient Safety Goal: Accurately and Completely Reconcile Medications Across the Continuum of Care Date: Performance Measures/Outcomes Method Volume Measure/ Numerator Benchmark Goal Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total - # of patient admission forms/ medication reconciliation forms sent to Medical Record without complete list of current patient/resident/ client medications QA Department review of medical record and patient drug profile # of admissions per month 0/# of admissions 0% - # of Discharge Instruction Sheets without complete listing of medications upon discharge Random medical record review 20 records per month 0/20 0% - # of Transfer Summaries without complete listing of medications at time of patient/resident/ client transfer Random medical record review 20 records per month 0/20 0% - # of medication errors related to lack of information about patient’s current medication regimen QA/PI Reporting (incident reporting) # of errors related to lack of patient information per total # of errors reported 0/# of incidents 0% 139