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Background/ Context - Every fall Toronto Public Health (TPH) delivers 425 vaccine clinics at schools. In fall 2016, TPH experienced an increase in medication incidents (MIs) at these clinics. Due to the volume of schools and students we serve, the clinic schedule is tight. Fall clinics need to be fully complete in order to ensure proper spacing of doses for subsequent spring clinics.

Aim/ Objectives - To identify potential underlying factors contributing to MIs and reduce their occurences in fall 2017.

Measures –

Primary outcome

1. # MIs from September – December 2017

Balance

1. # incomplete clinics from September – December 2017

Improvement/ Innovation/ Change Ideas –

Recognizing that frontline staff understand the reality of clinics, we conducted a staff only Root Cause Analysis (RCA) to explore underlying factors contributing to MIs. Two focus groups were conducted with a total of 16 staff. One focus group was with TPH staff and the other with contracted agency staff. Two Quality Improvement Specialists used fishbone diagrams and 5-Why's to identify potential root causes of two major categories of MIs, i.e. consent related and vaccine spacing related. The fishbone diagrams were analyzed using qualitative coding and impact vs control analysis to identify the top priority areas to address. Analysis was validated with group participants.

Impact/ Lessons Learned/ Results –

Key RCA Findings

Priority areas identified through analysis were:

• Reduce time pressures at clinic
  • Need to revise consent form layout for greater completion
  • Include pre-clinic consent screening in business processes
• Address keys staff learning needs
  • Change training methodologies to combine procedural and electronic database components

Results

After dedicated efforts by staff and management on the priority areas, results showed:

Discussion/ Spread -

Engaging frontline staff in a structured process can sucessfully help tackle complex problems. Not only are staff uniquely placed to identify key underling root causes but their active engagement fosters commitment and allows them to be owners of solutions.