Problem: An opportunity existed to improve practice, safety, and efficiency in our Allergy and Immunology Clinic. A patient received a wrong dose of an allergy injection and the root cause analysis revealed issues related to scheduling, staffing, space limitation, and practice not in accordance with national recommended standards as defined by AAAAI and The Joint Commission (TJC). The corrective action plan included monthly chart audits that uncovered several errors in dosing, including discrepancies between the paper and electronic record documentation and inadequate billing for services.

Business case: Process improvement will demonstrate the value of patient safety in the Allery and Immunology Clinic. A safer, more efficient process will improve quality and safety of care, staff morale, and staff turnover. Productivity targets aligned with staffing resources in the clinic will also contribute to decreased staff stress, potential decrease in staff turnover, and increased patient satisfaction. Proper billing for services and reduction of waste in the current system would also contribute to a positive return on investment.

Project objectives
1) Reduction of dosing and administration errors in the Allergy and Immunology Clinic.
2) Convert allergy documentation from paper to electronic charting in the electronic medical record (EMR).
3) Identify and implement best practices for the Allergy and Immunology Clinic.

Method: Using the DMAIC methodology (a data-driven improvement cycle used for improving, optimizing, and stabilizing processes), a quality improvement team was tasked to address the issues. The team consisting of leaders, nurses, physicians, and administrative staff identified several contributing factors: duplicate work, practice variation among providers and nurses, and no dedicated time or space to check orders. The team also noted volumes in the clinic had increased 45% over the previous 2 years, with no additional staffing resources.

Interventions: The immediate mitigating responses included the following:
• Timely verification process (two nurses manually verifying dosage)
• Expanded scheduled injection times to ensure dedicated 15 minute appointments
• Eliminated double booked appointments
• Adopted standard medication labeling process
• Conducted practice audits and provided results and recommendations to clinicians
• Revised associated policies and procedures
• Identified the paper charting as the “source of truth” until the electronic medical record can be upgraded to meet documentation requirements
• Standardized electronic documentation of visit notes
• Provided knowledge sharing with our community group practices

Results: Through this improvement project, two significant outcomes were achieved: construction of a larger medication and treatment room and revised onboarding and ongoing education and competency program.

This project successfully created a safer, more efficient process. Data demonstrates a significant decrease in the number of errors; clinicians meet AAAAI practice standards and TJC regulatory requirements, and the work has positively improved staff morale. The work also helped to build consistency and partnerships across the Dartmouth Hitchcock system.

While the project came to completion opportunities still exist and the leadership team continues to explore how to optimize our use of the EMR, support the work in the clinic, and collaborate with pharmacy and contracting partners to improve safety and efficiency.

Ericka Bergeron MSN, RN

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