Safe Practices to Decrease the Inherent Risk of High Alert - - PowerPoint PPT Presentation
Safe Practices to Decrease the Inherent Risk of High Alert Medications Meghan Duck, RNC-OB, MS, CNS Perinatal Outreach UCSF Benioff Childrens Hospital May 2018 1999 IOM Report To Err is Human: Building a Safer Health System An estimated
Meghan Duck, RNC-OB, MS, CNS Perinatal Outreach UCSF Benioff Children’s Hospital
May 2018
An estimated 44,000 - 98,000 people die each year from medical errors in hospitals “The equivalent of a jumbo jet crashing every day” New studies have shown these numbers are increasing.
Khon 2000, Wachter 2004
▪ The health reporter for the Boston Globe….
▪ Additionally
‒ died during minor surgery ‒ Drug mix up
Preventable Medical Errors ranked above Diabetes, Alzheimer’s, and Influenza A 2016 follow-up to the IOM study by Johns Hopkins researchers found medical errors were underestimated.
Severe outcomes of medical errors
High Alert Medications
Oxytocin Magnesium Epidural infusion Opioids Heparin Insulin
▪ Some Background ▪ 1998 The Quality of Healthcare in America project ‒ Develop a strategy that will improve quality
‒ Review and synthesize literature ‒ Develop communication strategies ‒ Articulate framework of incentives/foster accountability ‒ Identify factors that improve quality of care ‒ Develop research agenda
▪ Medication errors cause temporary harm, ▪ Disability, and death ▪ The human costs are incalculable ▪ The financial cost is estimated, and very likely underestimated.
▪Most common reason for malpractice lawsuits
HHS 2010
▪Medical Error- “ The failure to complete a planned action as intended or the use of a wrong plan to achieve an aim” (IOM) ▪Adverse Event- “ An injury caused by medical management rather than by the underlying disease or condition of the patient.”
Any interruptions along the way of this path can cause errors and lead to adverse outcomes.
▪ Systematic validation and verification of medical history and
▪ It involves comparing a patient’s current drug prescription with all medications currently taken ▪ It should be undertaken at every transition of care. ▪ Top causes of reconciliation errors include:
Avoid omissions Duplications Dose errors Drug interactions
▪ There are 5 main steps: ▪ 1) develop a list of current medications ▪ 2) develop a list of medications to be prescribed ▪ 3) compare the medications on the two lists ▪ 4) make clinical decisions based on the comparison ▪ 5) communicate the new list to appropriate caregivers and to the patient.
▪Labor & Delivery 2218 48.4 ▪Maternity Unit 2143 46.8 ▪OB PACU/Recovery 222 4.8 ▪Total 4583 100
Obstetrical Area n Percent
Kfuri et al. (2008) Data from 1/1/2003 – 12/31/2005
▪Staffing Levels – high nurse/pt ratio, rushing, no breaks ▪RN skill mix – heavy burden ▪Shift length – 12h (3X’s ) v/s 8h, also time of day/week ▪Patient acuity – higher stress on RN ▪Organizational climate
Other factors contributing to med errors by nurses Long work hours – shifts ▪Fatigue ▪Inefficient care process ▪Workplace design ▪Workload of documentation ▪Lack of knowledge of medication ▪Sources Institute of Medicine and Hewitt ▪Mathematical errors ▪Environmental stressors ▪Communication problems ▪Not following the 5 Rights ▪Look alike/ Sound alike medications
▪Do nurses lose interest over time? ▪Is it because they are no longer being observed? ▪Are they overburdened with heavy workloads ▪Are they emotionally affected?
▪Described as people who think for a living ▪Valued by society for their:
▪Must have high quality cognitive processing ability ▪Patients/ Family may interpret as:
▪Our brain is busy “juggling”
▪Interruptions - q 11 minutes / 25 minutes to resume ▪Distractions
‒ Requires complex mental activity to control
‒Requires anticipatory planning – i.e. vests, zones
momentum is difficult and cannot easily be controlled. ▪Multitasking ▪Lack of focus ▪Task switching
▪The human brain
▪Back and forth when trying to simultaneously process
▪Maximum # of items people can consciously hold is 4 ▪The ability to switch is diminished with age
Clark, A. et al. (2012) Clinical Nurse Specialists
▪Avoid engaging in nonessential communication ▪Medication administration checklist ▪Teamwork: having other staff cover telephone calls and interruptions
Flanders & Clark; Clinical nurse specialist (2010), vol 24 (6)
▪ Older adults fared differently when compared to young adults ▪ N = 40 20 ~age 24.5 Y=20 with ~ 20 ~age 69 ▪ Older –
▪ Aging does appear to cause loss of multitasking function ▪ It’s more difficult to switch tasks easily ▪ Older nurses often likely to be pulled ▪ Respectful approach
▪Maintain Safety ▪Manage the environment
away
▪3 level of errors have been identified 1.Skill based (slips and lapses) 2.Rule based (poor choices or inappropriate rules) 3.Knowledge-based (apply thinking to new situation)
▪Medication errors are under reported
reported Brady, A., et al. (2009).
Gladstone, 1995; Mayo et al., 2004; Ulanimo et al., 2007
five rights
▪Uncertainty if the medication error must be reported ▪Fear of disciplinary action if medication error is reported ▪Therefore evaluation to identifying root causes
▪What is the process for administering medications at your institution? ▪How has this process changed since you entered nursing? ▪What do you consider a medication error? ▪What procedures exists to decrease medication errors on your unit? ▪What is the role of pharmacy/technology in preventing med errors?
▪What is the process for reporting medication errors at your institution? ▪If you have made a medication error, and are willing, please respond to the following:
and reported it.
did not report it. ▪How would you change the process of reporting med errors today?
▪Andrenergic agonists
▪Andrenergic antagonists
▪Anticoagulants
▪Dextrose ▪Epidural medications ▪Insulin, Oral Hypoglycemics ▪Narcotics ▪Specifics
2008 Consensus Report Standards for Perinatal Care
The safe practices are defined as: processes that should be universally used in healthcare settings to: reduce the risk of harm resulting from:
care
implements a national strategy for healthcare quality measurement and reporting.
set of practices targeted at improving patient safety.
– T = 98.0 – HR = 92 – BP = 132/92 – R = 20
Questions:
▪2007 Dennis Quaid’s twins were given 1000-fold
Automated Dispensing Cabinets (ADC) Pyxis ▪At that time the packaging for heparin and heparin lock flush were very similar ▪Bar code scan was developed to correct the process error Chasing Zero
▪BCMA brings trade-offs
‒ When Hard Stops fail
▪for PE
▪Side effects
‒ Protamine sulfate 1mg neutralizes 100 units of heparin ▪ Should not exceed 50 mg
▪Initial treatment in single dose
▪Follow aPTT 4 hours after initiation and after dose changes ▪Goal with heparin therapy: aPTT 1.5 -2.5 x control (60-80 seconds) ▪Monitor coagulation lab trends ▪Risk of epidural or spinal hematoma
– Calcium antagonist Inhibits voltage independent calcium channels at the myometrial cell surface
– Not confirmed – Cochrane review
– Safe and familiar, neuroprotective
– Flushing, nausea, blurred vision, headache, pulmonary edema, cardiac arrest - caution if creat >1.0
ACOG Practice Bulletin. #43, 2003 Iams, J. Obstetrics: Normal and Problem Pregnancies, 4th d., 2002; Preterm birth, Williams Obstetrics, 22nd ed., 2005.
#1 Tocolytic used in the U.S.
▪ Magpie trial established 1 gm/hr dose effective ▪ Controversy over whether MgSO4 is needed in mild preeclampsia when closely monitored
leading to maternal death involved inattention to BP control and S/S of pulmonary edema
Clark, S. Maternal death in the 21st Century. Am J Obstet Gynecol, 2008
Development of the California Toolkit ‘Improving Health Care Response to Preeclampsia’ was funded by the California Department of Public Health (CDPH), Center for Family Health, Maternal Child and Adolescent Health (MCAH) Division, using federal Title V MCH funds.
Maurice Druzin, MD – Stanford
Elliott Main, MD – CMQCC Barbara Murphy, RN – CMQCC Tom Archer, MD – UCSD Ocean Berg, RN, CNS – SF General Hospital Brenda Chagolla, RNC, CNS – UC Davis Holly Champagne, RNC, CNS – Kaiser Meredith Drews – Preeclampsia Foundation Racine Edwards-Silva, MD – UCLA Olive View Kristi Gabel, RNC CNS – RPPC Sacramento Thomas Kelly, MD – UCSD Claire Brindis, DrPH, UCSF Dana Hughes, DrPH, UCSF
Larry Shields, MD – Dignity Health
Nancy Peterson, RNC, PNNP – CMQCC Christine Morton, PhD – CMQCC Sarah Kilpatrick, MD – Cedars Sinai Richard Lee, MD – Univ. of Southern California Audrey Lyndon PhD, RNC – UC San Francisco Mark Meyer, MD – Kaiser SD Valerie Cape – CMQCC Eleni Tsigas – Preeclampsia Foundation Linda Walsh, PhD, CNM – UC San Francisco Mark Zakowski, MD – Cedars Sinai Alana Moore Michael Orosco, MD ,Kaiser San Diego
4
▪4 – 6 grams bolus over 15 -20 min per institution P&P
▪For eclampsia – use smart pump (Alaris) library ▪2 RN check ▪RN remains at bedside for duration of bolus (staffing?)
gram) slow IV push over 3 minutes ‒Calcium Gluconate override from Pyxis ❖may repeat every hour, if needed, up to eight
doses/24 hours
▪Each institution should prepare its own medication toolbox specific to its protocols
Conditions that make accidents more likely
▪Different protocols, policies, procedures from one unit to another ▪Multiple pump settings ▪Inadequate labeling of IV fluids ▪Not removing the Magnesium from the IV port when it is has been discontinued ▪Thinking women on Magnesium are “stable” ▪Assumptions and miscommunication between nurses and/or physicians
1to diagnose preeclampsia with new onset hypertension.
eliminated from the diagnosis of severe preeclampsia.
threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic. The term “mild” preeclampsia is discouraged for clinical classification. The recommended terminology is:
18
severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild).
severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications.
and gestational hypertension.
19
education for early detection during and after pregnancy is important.
discussed.
▪Use of preeclampsia-specific checklists, team training and communication strategies, and continuous process improvement strategies will likely reduce hypertensive related morbidity. ▪Use of patient education strategies, targeted to the educational level of the patients, is essential for increasing patient awareness of signs and symptoms of preeclampsia.
71
A 27 y.o was admitted to L&D with cramping, abdominal pain, vaginal bleeding and leaking of clear fluid at 27 wks In an attempt to stop preterm labor, the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2g/hr A 20g/500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 g/hr
The pt. became flushed, short of breath, she called for a nurse. The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive CPR was initiated, magnesium infusion stopped and she was given a dose of Ca Gluconate The pt responded to emergency treatment - the baby was delivered by C/S a few days later d/t unrelated preterm complications Both mom and baby were discharged w/o harm?
▪Use of 1,000ml IV bags w/40 g of MgSO4 ▪Temporary removal of the IV line from the IV pump ▪A busy unit and/or understaffing ▪Transfer to a lower level of care ▪Unwitnessed respiratory arrest
▪Frequently assess VS, O2 sat, DTR’s, and level of consciousness, FHR and uterine activity ▪Assess for signs of toxicity (visual changes, somnolence, flushing, muscle paralysis, loss of patellar reflexes) or pulmonary edema and notify the MD if observed ▪Subsequent assessment
– Beta-2 stimulation → ↑ cyclic AMP, ↓ Calcium
– May delay delivery by 2 to 7 days
– Effective short-term arrest of contractions
– Maternal tachycardia, pulmonary edema, glucose intolerance – should only be given as inpatient – Not used as a 1st line or with OB patients with cardiac dz
– Dose
– Terbutaline 0.25 mg subcutaneously only, every 2 hr x 2
ACOG Practice Bulletin. #43, 2005: Normal and Problem Pregnancies, 4th ed., 2002; Preterm birth, Williams Obstetrics, 22nd ed.
2011 FDA issues warning
10.Meperidine
Ciarkowski,S., et al. (2010)
▪Oxytocin ▪Magnesium Sulfate Terbutaline ▪Terbutaline
▪21.9% of claims involving neurologically impaired babies ▪14.7% of claims involving stillbirth or neonatal death: included management of oxytocin ▪~ 1/2 of all paid claims involve allegation of oxytocin misuse
▪ Clark, Belfort & Dildy, (2006)
Induction of Labor Number 107, August 2009 Replaces Practice bulletin 10, Committee Opinion Numbers: 228, 248, 283
▪Classify indication and contraindications ▪Describes the various agents/methods used for IOL ▪Summarize effective agents based on outcome data ▪Outline the requirements for safe clinical use
▪Use National Institute of Child Health and Human Development (NICHD) terminology throughout the protocol ▪Clearly explain the purpose of the protocol ▪Describe pre-induction assessment of the patient
checklist ▪State any pre-induction documentation requirements ▪List the contraindications to labor induction
▪Describe the intrapartum physician and/or nursing assessment and documentation that may be required
▪List the parameters for discontinuation of the induction agent ▪Describe in detail interventions to be used if tachysystole, FHR abnormalities or other complications occur ▪Outline the notification process of providers should the induction agents be discontinued, or when nursing interventions do not readily resolve tachysystole, fetal heart rate abnormalities or other complications
▪The use of a checklist is highly recommended when administering oxytocin. ▪Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation. ▪The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institution’s Pitocin protocol.
Recommended Oxytocin “In Use” Checklist for Women with Term Singleton- Babies ▪“This Oxytocin “In Use” Checklist represents a guideline for care: however, individualized medical care is directed by the physician.” ▪Checklist will be completed every 30 minutes. Oxytocin should be stopped or decreased if the following checklist cannot be completed.
▪ At least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or adequate variability ▪ for 10 of the previous 30 minutes. ▪ No more than 1 late deceleration occurred. ▪ No more than 2 Variable decelerations exceeding 60 seconds in duration and ▪ decreasing greater than 60 bpm from the baseline within the previous 30 minutes.
▪ No more than 5 uterine contractions in 10 minutes for any
20 minute interval ▪No two contractions greater than 120 seconds duration ▪Uterus palpates soft between contractions ▪If IUPC is in place, MVU** must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg. ▪*If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated. ▪** MVU = Montevideo Units
▪Significant decrease in max rates of
increasing operative interventions. ▪Newborn outcomes improved ▪C/S rate dropped from 23.6% to 21% in 1 year ▪A 50% decrease in adverse outcome claims
Policy and Procedure: BC.20 BIRTH CENTER – Pt. Care
▪ 8 Pages ▪ HISTORY OF THE POLICY
▪ VIII. APPENDIX
▪1:1 Nursing
▪ “If an RN is not available to clinically evaluate the
effects of the oxytocin infusion at least every 15 min, the infusion should be discontinued until that level of care is available.”
▪ (AAP & ACOG, 2002 and AWHONN, 2002, 2010)
▪1:2 during induction/augmentation with oxytocin (AAP and ACOG Guidelines for Perinatal Care, 2007) ▪1:1 with high risk and active management
stage of labor
evaluate the effects of oxytocin at least every 15minutes (AAP & ACOG, 2007). ▪The oxytocin infusion should be discontinued if this level of nursing care cannot be provided. A LIP who has privileges to perform a cesarean birth should be readily available
▪ (AAP & ACOG, 2007)
a) Clear pain assessment b) Standardized order set
a) Prefilled labeled syringes b) Standardized concentration
a) Standardized infusion pumps (consider bar-coded technology) b) Education of patient regarding safe use of PCA c) No button use by proxy – only the patient uses the PCA button d) Independent double checks when changing syringes or changing infusion rates
a) Continuous pulse-oximetry b) Standardized monitoring parameters c) Use sedation scores
Number 447 • December 2009 (Replaces No. 286, October 2003)
▪Efforts to reduce the occurrence of these errors should be ongoing. ▪Computerized physician order entry systems can be effective in reducing prescribing errors, they are costly and may not collect data that support quality improvement activities. ▪In the absence of computerized physician order entry systems, the following steps should be adopted to reduce errors in prescribing and administering medications : ▪Improve legibility of handwriting ▪Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINION Number 447 • December 2009 (Replaces No. 286, October 2003)
▪Check for drug allergies and sensitivities ▪Always use a leading 0 for doses of less than 1 unit (eg, 0.1 mg, not .1 mg), and never use a trailing 0 after a decimal (eg, 1 mg, not 1.0 mg): “always lead, never follow” ▪All verbal orders should be written down by the individual receiving the order and read back.
Henneman, E. A., et al. (2010).
▪To describe error recovery strategies used by critical care nurses ▪Collected data from audio taped focus groups
▪17 strategies were identified
Henneman, E. A., et al. (2010).
forms
me?” *Novice or Physician
Henneman, E. A., et al. (2010).
Nurses used 3 strategies to interrupt errors:
(saving face)
The nurses ability to interrupt was influenced by:
Henneman, E. A., et al. (2010).
Nurses used 6 strategies to correct errors:
research article
Henneman, E. A., et al. (2010).
▪Nurses reported feeling :
▪Avoided some formal leaders
▪Conclusion
situation from reach or harming the patient
▪Full disclosure of errors to patients and families
Institute for Safe Medication Practice (2010)
▪Fair and Just Culture required ▪All “errors” tracked and catalogued, regardless of whether they reach the patient or cause harm ▪Errors viewed as systems failures, with examination of policies, EHR functionality, workflow issues, etc. ▪Recommendations made for templates, policies, workflow, and EHR functionality ▪Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
environment
leadership role
effectively
Allocate attention Wisely Utilize all available information Utilize all available resources Call for help early enough Maintain professional behavior
▪Sounds simple but it’s not ! ▪Emergency medications or equipment that is rarely used –where found?
‒arm boards, smart pump, pressure bags, rapid infuser ▪Equipment and supplies move ▪Staff vacations, relief/ float staff
Access to Emergency Supplies
▪Rearranged supplies and labeled bins ▪Stocked Emergency supplies in red bins & moved to upper shelves ▪Re-labeled frequent use bins with known names ▪Grouped related itemss
▪Quick access to emergency supplies ▪Refrigerator for meds ▪Establish necessary items and par levels ▪Label drawers/compartments ▪Include checklists ▪Develop process for checking and restocking ▪Educate nursing and physician staff
McNulty, 2014
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Draft 1.2
Shields, L., et. al., (2014) AJOG
▪ Checklist for protocol and data compliance
❑Risk assess ❑Correct blood bank request ❑Quantified blood loss ❑Correct lab results were obtained ❑> 2 Uterotonics give w/o MD present ❑Blood given per protocol
Safehealthcareforeverywoman.org
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system Clark, S., et. al., (2012) AJOG
▪Systematic approach to identify near-miss events on L&D
‒ Temporary verses permanent harm
‒ Weaknesses (Holes) ‒ Holes align
flow ‒ Reactive
‒ Proactive
▪Foster medical errors ▪Contributes to poor patient satisfaction ▪Contributes to preventable adverse
▪Increases the cost of care ▪Causes qualified clinicians, administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert, # 40, 7/08
The people who cared for their Mom are so sorry and we’re trying to learn from our mistakes. We’re working hard with all individuals at all levels to identify safety threats, and together we’ll find answers and get better at speaking up for patients like their Mom. We promise to do our best to create hospitals that are safe places to work free of fear and retribution. And because of the courage of their Dad and his work, nurses and doctors are better able to protect patients like their Mom and we have learned from this terrible mistake and it won’t happen again.
▪Martin Bromiley lost his wife in 2007. ▪He identifies, ‘we are all wrong no matter how good we are’. ▪We need people around us to tell us. ▪Be open to suggestions. Listen to your team. Step up and lead. Clear communication is key.
▪ Medication delivery is a complex multidisciplinary process.
▪The root causes of medications errors are multifactorial. ▪Nurses should clearly understand what constitutes a medication error. ▪A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change. ▪Health care providers need to work together to review errors and implement strategies that promote reliable,
safe systems.
▪ zdoggmd.com/ehr-state-of-mind/ ▪ http://zdoggmd.com/youre-welcome/
Meghan.duck@ucsf.edu
▪ACOG. (2009). Obstetrics & Gynecology. Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion
▪ACOG Practice Bulletin. #43, (2005). Normal and Problem Pregnancies, 4th ed., 2002; Preterm birth, Williams Obstetrics, 22nd ed.
▪Clark, A. et al. (2012). Clinical Nurse Specialists. ▪Clark, S. (2008). Maternal death in the 21st Century. Am J Obstet Gynecol,.
▪Clark, Belfort & Dildy, (2006) ▪Flanders & Clark; Clinical nurse specialist (2010), vol 24 (6) ▪Henneman, E. A., et al. (2010). ▪Kacmar, RM., Mhyre, JM. (2015). Obstetric Anesthesia Patient Safety: Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery. Anesthesia Patient Safety Foundation ▪McNulty, 2014 ▪Philadelphia Patient Safety Advisory. (2009). Dec 16;6 (Suppl 1):1-6. ▪Shields, L., et. al., (2014) AJOG ▪Stetina, P. et al (2005)