Quality Improvement Methodology Research Articles

Use of statistical process control in quality improvement projects in abdominal surgery: a PRISMA systematic review

BackgroundThe use of quality improvement methodology has increased in recent years due to a perceived benefit in effectively reducing morbidity, mortality and length of stay. Statistical process control (SPC) is...

1756 Improvement in the number of discharges prior to 3 p.m. using quality improvement methodology

Abstract Introduction Under current nationwide clinical pressures, hospitals are running at full capacity. Late discharges can lead to poor flow throughout the hospital, overcrowding in the emergency department and out of hours transfers, leading to a poor patient experience and impacts on patient safety. Early morning and afternoon discharges create better flow and improve patient satisfaction, by being home in time for tea. The discharge collaborative within Leeds Teaching Hospitals NHS Trust is a multidisciplinary team (MDT) of junior doctors, pharmacists, nurses and discharge co-ordinators. The aim of the team is to improve discharges in the trust prior to 3 p.m. to 70%. Discharging patients earlier in the day is a complex multifactorial issue which requires an MDT approach. Method To understand this further a retrospective case note review was conducted to look at avoidable and unavoidable causes of delayed discharges. Each team also received a questionnaire, to discover their perceived barriers to early discharges. This was communicated to teams to empower them to develop their own solutions which were shared within the trust. Run charts of discharges before 3 p.m. are published for each ward in the hospital every two weeks, which is available to wards, but also monitored by the discharge collaborative. Changes to practice include; education of the medical team regarding importance of timely discharge, use of discharge boards, the increase use of discharge lounge, identifying ‘golden patients’ for early morning discharges, prioritisation of community discharges the previous day and achievement recognition for wards with the most improvement. Results/Conclusions Within the trust, several departments have improved their discharges prior to 3 p.m. through the improvements implemented from the discharge collaborative, including speciality and integrated medicine (SIM), oncology, and trauma services. This project resulted in two step improvements within the Trust with 40% of patients being discharged before 3 p.m.

Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these...

1882 Treatment Escalation Plans (TEP): benefits in adult in-patient facilities

Abstract Introduction Treatment escalation plans (TEP) guide level of life sustaining therapeutic interventions that should occur for each patient admitted to hospital and can prevent inappropriate and undignified interventions. However, implementation of TEP in routine clinical practise has been ad hoc partly due to the paucity of literature on their benefits. Our aim was to systematically review the literature to ascertain the use and benefits of TEP in adults. Methods A systematic search for studies reporting TEP use were performed in the databases OVID Medline, Embase, Scopus and Web of Science. Search terms were ‘Treatment Escalation Plan’ Treatment Limitation, ‘Therapy Escalation’, ‘Escalation of Care’, ‘Palliative’, End of Life’, ‘Advanced Care Plan’. Exclusion criteria included studies prior to 2007, systematic reviews, case reports and letters. Results 468 records were retrieved, 117 duplicates removed, 351 records were screened. 302 were excluded by date or relevance. Of 49 eligible records, 39 were excluded by criteria or unavailability of full text articles. 10 Studies using case control and quality improvement methodology conducted between 2010-2022 involving 1614 patients were subject to a narrative review. 8 different TEP proformas were used. All studies reported an increase in TEP use across all clinical settings and after each PDSA intervention ranging from 78%-100%. TEP reduced the frequency of non-beneficial interventions and was associated with an average saving of £220 per patient. Conclusions TEP lead to more frequent and proactive discussions with patients on ceilings of care and provide clear guidance to clinical staff out of hours, facilitate patient handover over successive shifts and enable proactive discussions with critical care. We identified the need for TEP to be successfully implemented in a unified manner across all healthcare facilities in order to improve patient care, reduce the burden of non-beneficial interventions and align with the NHS Long Term Plan.

Sigma Metrics Assessment as Quality Improvement Methodology in a Clinical Chemistry Laboratory

Sigma Metrics Assessment as Quality Improvement Methodology in a Clinical Chemistry Laboratory

A qualitative study of adult protection procedures: threshold screening of new referrals by designated adult safeguarding practitioners

Purpose This qualitative study set within Northern Ireland aims to explore professional perspectives on the application of evidence-informed practice to the adult safeguarding threshold screening process. Design/methodology/approach Data was gathered from seven social workers in one health and social care trust area, who perform the designated adult protection role, through individual semi-structured interviews in one region of Northern Ireland. The interview schedule comprised of a series of questions examining the role of the designated adult protection officer and included three vignettes (Appendix). A thematic analysis was undertaken using NVIVO software. Findings This paper reports main findings under the themes of: the role of the designated adult protection officer, threshold decision-making, evidence-informed practice and service improvement. One of the main findings was that professionals viewed the current process as too bureaucratic, and there was a desire to engage in more preventive safeguarding in collaboration with service users. There was a need to promote awareness of evidence-informed practice as it applies to the threshold screening process. Furthermore, the study raised the question of the need to consider the application of models or methods of assessment to the threshold screening process. Originality/value This in-depth exploration of the role of designated adult protection officers in Northern Ireland provides a valuable insight into the complexity involved in managing adult safeguarding referrals and investigations. This study adds to the existing knowledge base, identifies potential service improvements and highlights the gap in evidence-based practice as it applies to the threshold screening process. Threshold screening of adult safeguarding referrals remains a subjective process and is open to interpretation and differences in professional judgement. The study highlights the need to consider the application of quality improvement methodology to the threshold screening assessment and the need to promote the exchange of safeguarding knowledge.

Statistical process control and PDCA for quality improvement in the mexican automotive industry

Despite the advancements witnessed in the realm of quality improvement, Statistical Process Control (SPC) perseveres as a universally embraced and extensively employed tool within manufacturing companies across the globe. This enduring popularity can be attributed to its adherence to the time-tested principles established by Shewhart, which have withstood the test of time since their inception in 1924. Over the years, SPC has consistently proven its efficacy in optimizing manufacturing processes, enhancing product quality, and fostering continuous improvement initiatives. Quality is an utmost necessity in the automotive industry, which ranks as the 3rd most significant industry in Mexico and the 5th globally in terms of volume and transactional activity. This research focuses on a successful real case study that demonstrates the enhancement of capability in a critical machining operation within an automotive plant located in Mexico, specifically dedicated to truck engine remanufacturing. This improvement was achieved through the analysis of x̅ and R control charts, followed by the implementation of the Plan-Do-Check-Act (PDCA) cycle. The results obtained were derived from a comparative analysis of data from two distinct time periods in the machining process of bushing diameters. This analysis revealed a significant increase in process capacity, with a 13.08% improvement in the Process Capability Index (Cpk) and a 17.2% enhancement in the Process Performance Index (Ppk). The decrease in expected out-of-specification parts showed a remarkable improvement of 72.7%. Additionally, there was an enhancement in process variability, with a notable 8.33% reduction in the mean range. The significance of this research lies in its empirical identification of gaps and opportunities within the realms of quality assurance and quality control, utilizing methodologies for quality improvement. By uncovering these gaps and opportunities, this study provides valuable insights that can guide future efforts to enhance quality practices and drive continuous improvement in the field.

Implementation of an automated transition readiness assessment in a pediatric rheumatology clinic.

Failure of successful transition to adult care for adolescents and young adults with chronic rheumatic diseases negatively impacts their health and wellbeing. Transition of care is a vital and complex process within pediatric rheumatology that can be difficult to execute. Use of quality improvement (QI) and clinical informatics (CI) can help implement transition programs. Despite efforts to improve transition of care within our pediatric rheumatology clinic, it has been difficult to implement and sustain good transition practices including assessment of transition readiness. Using QI methodology and CI, this study aimed to improve transition readiness assessment from 12 to 30% and sustain for one year by surveying transitioning patients yearly. A transition-focused QI team utilized methods endorsed by the Institute for Healthcare Improvement and leveraged CI to improve survey completion. Control charts of survey completion rates were tracked monthly. Descriptive statistics were used to analyze survey responses. Interventions focused on automation of patient surveys at regularly scheduled clinic visits. 1,265 questionnaires were administered to 1,158 distinct patients. Survey completion rose from a baseline of 12% to greater than 90% and was sustained over 18 months. Identified educational needs included health insurance, scheduling appointments, obtaining care outside of rheumatology clinic business hours, Electronic Health Record messaging, and refilling medications. By leveraging CI and QI methodology, we were able to assess transition readiness in more than 90% of our patients and identify gaps in self-management. Process automation can create sustainable transition practices.

A pilot model of care to achieve next-day discharge in patients undergoing hip and knee arthroplasty in an Australian public hospital setting.

Objectives Internationally, hip or knee arthroplasty (TJA) with a 1-day hospital length of stay (LOS) is common and demonstrates improved patient and health service outcomes. This study aimed to develop and pilot an enhanced recovery program (ERP) for patients undergoing TJA to achieve a next-day discharge in an Australian public hospital setting. Methods A project lead and six perioperative clinical craft group leads developed an ERP protocol based on enhanced recovery after surgery (ERAS) principles. Strict patient eligibility criteria were developed. Quality improvement methodology was used to implement the ERP. A patient navigator was put in place as a single contact point for patients. Results A total of 825 patients were screened for the ERP and 47 patients completed the protocol. The mean ± standard deviation (s.d.) of the LOS was 34.7 (± 7.2) h with 41 patients (87%) achieving next-day discharge, the remaining six (13%) discharged on Day 2. Compliance with ERAS was high (96%) with mobilisation within 12 h occurring on 87% of occasions. There were no adverse events. Patient experience was positive. Conclusion Next-day discharge was achieved with a selected cohort of patients with no adverse events and positive patient experience, using a multidisciplinary approach and an improvement framework. Broadening inclusion criteria will make ERP available to more patients.

Advancing language concordant care: a multimodal medical interpretation intervention

BackgroundEnsuring language concordant care through medical interpretation services (MIS) allows for accurate information sharing and positive healthcare experiences. The COVID-19 pandemic led to a regional halt of in-person interpreters, leaving...

Using Clinical Decision Support Systems to Decrease Intravenous Acetaminophen Use: Implementation and Lessons Learned.

Clinical decision support systems (CDSS) can enhance medical decision-making by providing targeted information to providers. While they have the potential to improve quality of care and reduce costs, they are not universally effective and can lead to unintended harm. To describe the implementation of an unsuccessful interruptive CDSS that aimed to promote appropriate use of intravenous (IV) acetaminophen at an academic pediatric hospital, with an emphasis on lessons learned. Quality improvement methodology was used to study the effect of an interruptive CDSS, which set a mandatory expiry time of 24 hours for all IV acetaminophen orders. This CDSS was implemented on April 5, 2021. The primary outcome measure was number of IV acetaminophen administrations per 1,000 patient days, measured pre- and postimplementation. Process measures were the number of IV acetaminophen orders placed per 1,000 patient days. Balancing measures were collected via survey data and included provider and nursing acceptability and unintended consequences of the CDSS. There was no special cause variation in hospital-wide IV acetaminophen administrations and orders after CDSS implementation, nor when the CDSS was removed. A total of 88 participants completed the survey. Nearly half (40/88) of respondents reported negative issues with the CDSS, with the majority stating that this affected patient care (39/40). Respondents cited delays in patient care and reduced efficiency as the most common negative effects. This study underscores the significance of monitoring CDSS implementations and including end user acceptability as an outcome measure. Teams should be prepared to modify or remove CDSS that do not achieve their intended goal or are associated with low end user acceptability. CDSS holds promise for improving clinical practice, but careful implementation and ongoing evaluation are crucial for maximizing their benefits and minimizing potential harm.

Implementation of an Anterior Mediastinal Mass Pathway to Improve Time to Biopsy and Multidisciplinary Communication.

Mediastinal masses in children with cancer present unique challenges, including the risk of respiratory and hemodynamic compromise due to the complex anatomy of the mediastinum. Multidisciplinary communication is often a challenge in the management of these patients. After a series of patients with mediastinal masses were admitted to Riley Hospital for Children Pediatric Intensive Care Unit, the time from presentation to biopsy and pathology was greater than expected. We aimed to reduce the time to biopsy by 25% and demonstrate improved multidisciplinary communication within 6 months of protocol implementation for patients presenting to Riley Hospital for Children Emergency Department with an anterior mediastinal mass. Quality improvement methodology created a pathway that included early multidisciplinary communication. The pathway includes communication between the emergency department and multiple surgical and medical teams via a HIPPA-compliant texting platform. Based on patient stability, imaging findings, and sedation risks, the approach and timing of the biopsy were determined. The pathway has been used 20 times to date. We successfully reduced the time to biopsy by 38%, from 25.1 hours to 15.4 hours. There was no statistically significant reduction in time to pathology. The multidisciplinary team reported improved communication from a baseline Likert score of 3.24 to 4. By initiating early multidisciplinary communication, we reduced the time to biopsy and pathology results, improving care for our patients presenting with anterior mediastinal masses.

Improving food insecurity screening across a health system throughout the COVID-19 pandemic

BackgroundFood insecurity has direct and indirect negative outcomes on the physical and mental health of children, with impacts throughout adult life. Rates of food insecurity have increased dramatically since the...

Electronic health record modification and dashboard development to improve clinical care in pediatric rheumatology.

This report describes our experience in electronic health record (EHR) note modification and creation of an external dashboard to create a local learning health system that contributes to quality improvement and patient care within our pediatric rheumatology clinic. We applied quality improvement methodology to develop a more reliable and accurate system to identify patients with juvenile idiopathic arthritis and track important measures that aide in improving patient care and performance outcomes. From 2019 to 2021, we iteratively modified our outpatient clinic EHR note to include structured data elements to improve longitudinal monitoring. We then validated data transferred to an electronic dashboard external to the EHR and demonstrated utility for identifying an accurate patient population and tracking quality improvement initiatives. Creation of the structured data elements improved the identification of patients with JIA with >99% accuracy and without requiring manual review of the chart. Using the dashboard to monitor performance, we improved documentation of critical disease activity measures that resulted in improvement in those scores across the local population of patients with JIA. The structured data elements also enabled us to automate electronic data transfer to a multicenter learning network registry. The structured data element modifications made to our outpatient EHR note populate a local dashboard that allows real time access to critical information for patient care, population management, and improvement in quality metrics. The collection and monitoring of structured data can be scaled to other quality improvement initiatives in our clinic and shared with other centers.

A Bundled Educational Solution to Reduce Incorrect Plaster Splints Applied on Patients Discharged from Emergency Department

Purpose: Plaster splints are routinely performed in the Emergency Department (ED) and avoidable complications such as skin ulcerations and fracture instability arise mainly due to improper techniques. Despite its frequent use, there is often no formal training on the fundamental principles of plaster splint application for a medical officer rotating through ED. We aim to use Quality Improvement (QI) methodology to reduce number of incorrect plaster splint application to improve overall patient care via a bundled educational solution.Methods: We initiated a QI program implementing concepts derived from the Institute for Healthcare Improvement models, including Plan-Do-Study-Act (PDSA) cycles, to decrease the rate of incorrect plaster splint application. A bundled education solution consisting of three sequential interventions (practical teaching session, online video lecture and quick reference cards) were formulated to specifically target critical factors that had been identified as the cause of incorrect plaster splints in ED.Results: With the QI intervention, our overall rate of incorrect plaster splints was reduced from 84.1% to 68.6% over a 6-month period.Conclusion: Following the QI project implementation of the bundled educational solution, there has been a sustained reduction in incorrect plaster splints application. The continuation of the training program also ensures the sustainability of our efforts in ED.

Designing and Implementing Integrated Care Using an SOP and Quality Improvement Methodology

Introduction: Implementing complex health service innovations, such as digitally enabled integrated care within real world conditions, is challenging, both at a project and programme level. ADLIFE is a large-scale implementation project, funded through the European Commission Horizon Europe programme. It focuses on the implementation of integrated care planning and management for patients with advanced chronic conditions, by coordinating all care providers, the patient and carers. It is supported by digital platforms for patient care planning, management and patient empowerment. The planning and monitoring of the implementation of the integrated care process and supporting technologies, in seven countries with very different healthcare systems, has required a systematic and collaborative approach that would enable deployment and continuous learning and evaluation.
 Theory/Methods: The methodology used was an adaptation of the Standard Operating Procedures (SOP) approach combined with a continuous monitoring and quality improvement methodology to support the adjustment and alignment of processes along the way in order to insure a successful deployment. An overall project SOP was developed collaboratively by the project management teams that met biweekly based on a model developed in ADLIFE’s precursor project - the C3 Cloud project . The SOP provided an “on-the-ground” explanation of what needs to happen to ensure the planning and deployment of the digitally supported integrated care process in all of the countries. It assures the requisite level of uniformity and the quality of outcomes, and reduces miscommunication and ambiguity among team members and project partners. The monitoring tool was based on the SOP to enable the identification of problems and obstacles in real time, in order to make the necessary changes and adjustments. Each implementation site developed a local adaptation in the form of a local operating procedures manual (MOP).
 Results: The collaborative development and implementation of the SOP and MOPs has facilitated a dynamic, yet systematic design for the implementation of the ADLIFE integrated care process and technologies in seven very different settings. It has provided a very effective and efficient project management methodology and tools for both overall and local project management teams, as well as systematic documentation for continuous improvement and evaluation.
 Discussion and Conclusions: Integrated care projects and programmes are challenging, even in a single location or system. They are even more complex when attempting to implement processes supported by common digital tools in multiple locations and systems. A set of clear organizing principles as elucidated using an SOP/MOP methodology provides a clear overall structure that supports both a requisite level of commonality and uniformity for purposes of comparison and evaluation while enabling sufficient flexibility for adaptation to local needs and conditions. 
 Limitations and Future Research: The SOP approach has been implemented in a H2020 project in specific sites in seven countries. The method needs to be tested and refined in the implementation of regional and national integrated care programs.
 Acknowledgments: This work is a part of the ADLIFE project under HORIZON 2020 grant agreement no. 875209 and submitted on behalf of ADLIFE consortium

The introduction and impact of a National Frailty Education Programme

Background: Frailty is a dynamic functional state. Its onset and progression can be reduced and even reversed, if early intervention and correct management strategies are set in place. A number of reports suggest that healthcare professionals in general, have a poor understanding and view frailty as an inevitable part of ageing. In response the NCPOP developed The National Frailty Education Programme
 Aim: The programme aim is to provide healthcare professionals with an enhanced understanding of frailty and frailty assessments; thereby ensuring earlier recognition of frailty, improved healthcare management, and better outcomes for older adults living with frailty.
 Methods: A Test of Concept, using quality improvement (QI) methodology was employed. This allowed for small tests of change, which informed the development of the programme content and the programme delivery.
 Results: From 21st September 2017 to December 2019 n=3045 healthcare professionals completed the programme. A further 87 staff attended the programme during 2020. 
 97% of respondents rated the programme highly in relation to their level of enhanced understanding following participation in the study day.
 In early 2020, due to the outbreak of the COVID-19 the pandemic face to face education had to cease. The impact of COVID-19 on older adults and the increased prevalence of frailty on this cohort meant the development of and access to an eLearning programme became a priority and an eLearning programme was developed. A blended programme is due to be launched in 2023.
 Impact: In 2018, the NFEP was awarded the Zenith Global Healthcare Award in recognition of its pioneer educational approach to the delivery of integrated interprofessional education. The programme has also been included in the European Union’s Joint Action on Frailty Prevention (Rodríguez-Laso et al., 2019), as a case study of good practice under Domain 7: Education and Training. Many other projects, publications and developments have arisen out of this programme including: the evolving Frailty Networks nationally, the inaugural meeting of the Irish Frailty Network of the Irish Gerontological Society in September 2019 , the first All-Ireland Frailty Network meeting in October 2021 , advisory inputs to the Northern Ireland Frailty Network in November 2021 towards developing a Frailty Education Programme for Northern Ireland, and many other initiatives and contributions to improve patient care. The programme has been cited internationally as an exemplar of an interprofessional approach to learning (Walsh, & Currid 2018, Adja, et al. 2020, Munro & Murphy, 2022, Romero-Ortuno, et al. 2022); in recognition, since 2022, Trinity College Dublin offers up to 5 annual scholarships to NFEP Facilitators for the online, standalone module in Assessment and Management of Frailty in Ageing Adults .

Utilizing Community Health Ambassadors to improve COVID-19 vaccine uptake in equity priority neighborhoods in Toronto, Canada

East Toronto Health Partners (ETHP) is comprised of 100+ health and social organizations, with a leadership council consisting of patient/caregivers and six anchor organizations representing the continuum of care. During the pandemic ETHP implemented a Community Health Ambassador (CHA) Model to increase access to COVID19 vaccinations in underserved neighborhoods through health promotion activities and referral to COVID19 outreach Centers (CoCs).
 The intervention focuses on equity priority neighborhoods with significant concentrations of underserved populations including but not limited to newcomers and households with low incomes.
 Early in the COVID-19 pandemic it became apparent that the impact was disproportionally high in equity priority neighbourhoods. Once COVID19 vaccine became available to the public, it became evident that the wealth of knowledge residing within the community was essential to improve vaccine uptake, particularly in priority neighbourhoods. ETHP partnered with the community to co-design outreach strategies. A particularly meaningful partnership was the collaboration with community members who assisted us in designing our CHA model. The CHAs program was administered through one of the community ETHP health service providers.
 CHAs were localized to the neigbourhood where they lived and utilized their knowledge of the community to identify and address misinformation and barriers to vaccination. CHAs were able to engage in individualized educational interventions locally and escalate systemic barriers to the ETHP. These issues were addressed through rapid cycle change quality improvement methodology by the members of the ETHP.
 From December, 2021 to March, 2022, we engaged and deployed 197 CHAs to conduct outreach activities. They reached out to over 25,000 individuals in our priority neighbourhoods. Their work bridged the equity gap in vaccination. In September 2021, there was a 20% point difference in 1st dose coverage between the most vaccinated and least vaccinated neighborhoods in East Toronto; in March 2022, this difference decreased to 16% partly as the result of CHA outreach in priority neighborhoods.
 Barriers to vaccine uptake could best be identified by hyper-local strategies implemented by CHA with a deep understanding of the local neighborhood. The barriers identified by CHAs could be addressed with the help of an integrated health system to improve equitable delivery of COVID-19 vaccine.
 Based on the success of the CHA model were are co-designing a strategy to utilize CHAs to assist with health care recovery focusing on other preventive interventions that not equitably delivered such as cancer screening.

Addressing social determinants of health through customization: Quality improvement, telemedicine, and care coordination to serve immigrant families.

The purpose of this project was to establish a pathway for electronic medical record (EMR) customization, utilizing quality improvement methodology, to both identify and address adverse social determinants of health (SDOH) among a diverse spina bifida (SB) population. Starting in September 2020, the four fundamental steps were to (1) facilitate an advisory committee to safeguard the standard clinical protocols, (2) characterize barriers to implementation, (3) evaluate workflow to sustain data entry capture, and (4) manage the technology platform for seamless integration. The SB clinic was the first clinic within the enterprise to rollout the use of an adverse SDOH mitigation activity. A Spanish-speaking interpreter was scheduled for all clinics, as many families were limited in English proficiency. The customization of the EMR to support an efficient workflow to address SDOH was feasible in a large and diverse urban medical center. Of the 758 patients served in the clinic, a myelomeningocele diagnosis was present in 86% of individuals. While 52% of participants were female, ethnically 52% of individuals served were Latino. Many of these individuals disclosed being recent immigrants to the United States. Often immigration and asylum related issues were at the forefront of the SDOH issues addressed. Given the occurrence of adverse SDOH among individuals with SB, many of whom are new Latin-American immigrants, meaningful clinical efforts are needed to both identify and address the causes of the observed disparities. EMR customization is feasible and can identify and, through social prescriptions, address SDOH to support the provision of safe, high quality, and equitable care for vulnerable and medically complex populations at home and potentially abroad.

Increasing optimal coagulation factor dosing in the paediatric emergency department: Update to a quality improvement study.

Prompt, appropriate coagulation factor replacement according to injury and bleeding severity in persons with haemophilia is required to prevent acute and long-term complications. Increase proportion of persons with haemophilia A (HA) and B (HB) treated appropriately for an acute injury and bleeding episode at a tertiary children's emergency department (ED) from 65% to 85% and sustain for one year. Secondary aim: increase time interval between patient ED encounters with out-of-range factor dosing. Utilizing quality improvement methodology and plan-do-study-analyze cycles, ED encounters for individuals with HA/HB receiving coagulation factor replacement for injuries were audited for in-range coagulation factor dosing. Goal factor dose defined as 50% correction for minor bleeds and 100% correction for major bleeds. Optimal dosing range defined as 90%-120% of the calculated goal dose to account for vial size variability. Interventions targeted communication via the EMR problem list and optimization of physician education. Our previous publication demonstrated 33.3% of ED encounters with out-of-range factor replacement. Following several interventions, the cumulative rate of encounters with out-of-range dosing decreased to 18%. Overall, there was an increase in the mean percent of encounters receiving optimal factor dosing for both HA/HB compared to baseline (82.2% vs. 71.1%), though this was not a statistically significant difference. Despite implementation of multiple interventions, out-of-range factor dosing continues to occur. Our team plans to reinstate simulation center education for ED staff and continue education efforts of pharmacists and hematology trainees with the goal of further reducing out-of-range dosing in our ED.