Transcript 2007 Safety Rules

2007 Safety Rules
AS REAL AS IT GETS
Mike Daly BSN, Nurse Manager
Diane Vacarro MS, CNS
Florence Toy PharmD
Arnold Dignadice RN
Mylene Espiritu RN
Daisy Cruz BSN, RN
Jignasa Pancholy RN
Lisa Holton RN
Celeste Arbis RN, BSN
Shino Honda RN, BSN
Integrated Nurse Leadership
Program -- INLP
• Funded by Gordon and Betty Moore
Foundation
• Directed by Center of Health
Professions at UCSF
• Work with Bay Area hospitals to
address issues of nurse retention
and patient safety
• This year’s goal: Safety Medication
Administration
This year’s participating
hospitals
• Kaiser Permanente, Fremont
and Hayward
• Novato Community Hospital
• St. Rose Hospital
• Sequoia Hospital
• Stanford Hospital
• San Francisco General Hospital
SFGH
2 Tests of Change
• Two Patient Identifiers
• Interruptions during Med Pass
CalNOC Data
100
90
99
87.3
Compared med with
MAR
85.6
Percent of doses
80
70
65.7
60
50
47.1
40
60.8
Med labed from prep
to admin
Checked 2 forms ID
Explained med to pt
30
20
10
0
111
Charted med
immediately after
admin
Interrupted during
admin
Med Pass
• Goal: To achieve 100% patient
ID check by using 2 forms
• Focus: Remind nurses to use
two forms of patient
identification (full name and
birth date)
Med Pass
Implementation
• Changes in exchange of report
• Patient information stickers on
report sheet and medicine cups
• Educating patients with posters
Med Pass
Results
Full Name and DOB Compliance Rate
70
120%
100%
90%
50
100%100%
100%
80%
83%
40
68%
60%
30
40%
20
20%
10
0
0%
1
2
3
4
week
5
6
Compliance rate
# of patients
60
Patient Controlled Analgesia
Data Collection
Independent vs. Dependent
Double Check
Interruptions
• Goal: Decrease non-urgent
interruptions
• Focus: Increase awareness of
interruptions which can lead to
medication errors
Interruptions
Definition
Non-Urgent
Urgent
• Non-productive
• Calls for
talk between
immediate action
nurses and other
or attention
health care
workers
• Non-urgent
phone calls
Interruptions
Implementation
• Signs placed in hallways &
medication room
• Unit clerk screens all nonurgent phone calls
• “Prevent Med Error” signs
Interruptions
Evaluation
Tool was developed to document the
types and frequency of interruptions
Interruptions
Results
Types of Interruptions
No Interruptions,
11
Non-Productive
talk in med room,
6
Phone calls, 9
Patient/family to
nurse interaction,
15
Other discipline
to nurse
interaction, 8
Nurse to nurse
interaction, 10
Interruptions
Results
Location of Interruptions
Did not state
8%
Med room
39%
Patient's room
28%
Hallway
25%
Interruptions
Results
Urgency of Interruptions
Did not state
25%
Urgent
17%
Non-Urgent
58%
Interruptions
Results
• Med Pass ID badge failed
• Increase in interruptions
• Nurses forgot to flip the badge
• Increase in awareness among
nurses and patients
• Current trial of med box
Change in Culture
• Goal: Change nurses’ attitudes towards
medication administration safety
• Focus: Encourage nurses to adapt new
processes
• Goal: Implement changes hospital
• Wide
Safety Comes First in
Medication
Administration!!