Implementation of an improved process at the Hospital of the University of Pennsylvania was sparked through the Shared Governance process; arising from staff nurse concerns. Subsequently, a clinically transdisciplinary team was formed, charged with developing a comprehensive plan for improving the process of potassium administration.  In keeping with the Iowa model of EBP, a literature review was completed, resulting in multiple transdisciplinary changes and successful implementation of  changed care delivery practices.   Prior to implementation, communication was through email and the nursing internet site, coupled with extensive in person discussions. Accurate documentation on the electronic medication administration record and pharmacy’s role in maintaining patient safety were both initiative priorities.. 

 A post implementation audit process included solicitation of staff’s perception through a variety of forums and “swat team” interventions when barriers to implementation occurred. Future plans include evaluating the usefulness of linking oral diet orders with electronic triggers to promote oral replacement and the use of automated barcode technology to compare delivery time and order time.

 Central to our process improvement plan was an emphasis on patient safety and the role of the bedside nurse in identifying and evaluating practice issues.  As our healthcare system continues to evolve into an increasing complex system of delivery, the processes by which simple procedures, such as electrolyte replacement, are accomplished can lend valuable insight into wide scale process improvement.