Amy McLaughlin, BSN, RN, PCCN Heather Cable, RN 1

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Transcript Amy McLaughlin, BSN, RN, PCCN Heather Cable, RN 1

Amy McLaughlin, BSN, RN, PCCN Heather Cable, RN Rutland Regional Medical Center 1

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 We work together on the Progressive Care Unit at Rutland Regional Medical Center (RRMC) in Rutland, Vermont.

 Our patient population is varied and consists of Cardiac, Pulmonary, and high-acuity patients who do not require Intensive Care.

 Our Unit’s Culture supports staff participation in various committees focused on patient safety and satisfaction.

 The fast-paced environment, combined with high patient turnover and acuity, reinforces the need for Nurse-led interventions aimed at improving patient care and outcomes.

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 We are members of the Progressive Care Unit (PCU) Patient Safety Team.

 We began as the Medication Safety sub-Committee  Initial interest in the project focused on improving the Medication Administration process on PCU 4

   Our first step was a review of PCU medication administration data.

An informal Research Question was the result… A Literature Review then followed…  …which helped guide us to our formal Research Question… 5

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We had to decide:

 What part of the Medication Process do we observe?

  We decided we needed to observe the ENTIRE process, from beginning to end… We needed to watch one Nurse, from the moment s/he entered the med room, until the final med was passed to that patient.

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One-Page Tool

Real Time

 Second to second 

Easy to Navigate

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 First draft was an excel spreadsheet tool…  Busy  Smallest time increment in minutes  …back to the “drawing board”… 11

Combined everything we needed:

 One, attractive, easy-to-read page  Time-Stamped (Second-to-Second)  Easy to Individualize  “One Click is All You Need”!!

…And Here’s How It Looks…

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7/9/2011 7/9/2011 7/9/2011 7/9/2011 7/9/2011 7/9/2011 7/9/2011 7/9/2011 7:28:02 AM 7:32:27 AM 7:32:50 AM 7:34:33 AM 7:34:58 AM 7:36:05 AM 7:36:28 AM 7:36:50 AM

TASKS

PHYSICIAN NURSE PATIENT OTHER CLINICAL PROFESSIONAL FAMILY PHARMACY/ OMNICELL COMPUTER TELEPHONE OTHER LNA CASE MANAGER RN SCANNER

MED ADMIN PROCESS TRUE

TRUE

TRUE

TRUE

TRUE

TRUE

TRUE TRUE

0:00:23 0:00:23 0:00:25

  Over a period of one week in July, 2011, medication passes were observed on PCU from 7am to 11am. A total of 67 passes were captured during Phase I of the Observation Process, using our tool.

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50 40 70 60 10 0 30 20 23 42 65 21

Total # Interruptions 67 Observed Med Administrations

14 24 9 2 1 23 14 6 16

80 70 60 10 0 30 20 50 40 75 38 49 45

Average Interruption Elasped Time

34 48 59 32 47 34 43 23 17

Implementation of Nurse-led Intervention Medication Room Etiquette “Respecting the Process”

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How Will It Look?

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How Did We Get Support?

Staff Pledge

I pledge to follow proper medication administration practices to ensure the safety of my patients, myself , and my fellow health care professionals.

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 We will implement our intervention for four weeks, beginning this Monday, November 14 th .

 We will then start Phase II of our Observation Study beginning the week of December 11 th .

 Final Data Analysis following Data Collection.

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     Will our Data support that our Intervention led to decreased interruptions?

Will our Intervention need an adjustment?

Might we go Hospital-Wide?

Might we Publish?

Perhaps other facilities will be able to use our Tool!

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