Improving Ambulatory Care Safety: Elimination of Injection Errors at Primary Care Physician Offices

The goal of this project was to reduce the number of injection errors occurring at the hospital's primary care clinics. After an increase of injection errors, it was determined that a standardized process was not developed after the implementation of the electronic health record. The project utilized the Design for Six Sigma model to develop a process to assist providers and nursing staff in providing error-free injections. Since implementing the new standardized process at the pilot clinic, only one injection error has occurred in 9 months. Injection errors were reduced from a 1.2 percent error rate to 0.1 percent for the pilot clinic. The new process has been implemented at several other provider clinics within the organization and will continue to be rolled out to all their clinics.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state. These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)