Table 1.

Interventions Implemented During One-year Period

Intervention Level and Status	Intervention Type	Number	Examples
Level 1 (easy quick fixes)
• Accomplished = 30	Education	25	Workshop on medical errors for residents. Practice with IVs for nurses. In-service for nurses on oxygen use. Education of MDs to include “purpose of medication” on all prescriptions.
• In progress = 6	Systems	15	Oxygen sats added to vitals for all COPD patients. Redesign of hemoccult notification processes and tracking system.
• Not yet attempted = 13	Equipment	9	Glucagon added to standard supplies in clinic.
Level 2 (higher complexity)
• Accomplished = 6	Education	3	Guidelines for lab monitoring “high-risk medications.”
• In progress = 8	Systems	12	Protocol for reporting of lab results based on severity of abnormality. Admission checklist (to standardize holding orders and the admission process). Redesign of no-show policy to assure appropriate follow-up.
• Not yet attempted = 3	Equipment	2	No-show follow-up form.
Level 3 (requires work with other clinics or departments)
• Accomplished = 6	Education	2	Education of radiology and medicine staff regarding policies and procedures for rapid read, film returns, and abnormal readings.
• In progress = 0	Systems	3	Establish communications between internal medicine and anticoag clinic. Centralized process for film returns.
• Not yet attempted = 1	Equipment	2	Radiology online images available in outpatient clinic. Electronic prescribing.

IV, intravenous lines; COPD, chronic obstructive pulmonary disease.