Improving Safety In the ICU by mikeholy

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									      Lakeridge Health Corporation

Narcotic (Opioid) Medication Safety Initiative
 Using: Process Flow Maps, Root Cause
  Analysis, Workflow Construction Charts,
            Risk Ranking Scales

                   QHN Fall Forum 2008
                                       Team Members
• Patricia Boyd, Registered Nurse, Post Acute Specialty Services,
  Bowmanville Site
• Thom Chambers, Director, Professional Practice
• Annette Down, Leader, Risk Management and Patient Safety
• Barb de Rond, Clinical Leader, Pharmacy, Bowmanville Site
• Pat Dingman, Clinical Leader, Post Acute Specialty Services,
  Bowmanville Site
• Francis Henke, Clinical Education Leader, Oshawa Site
• Denise Lamont, Quality Coordinator of Clinical Data for Post Acute
  Specialty Services Program
• Shelley McKinney, Director, Pharmacy
• Christena Selby, Site Leader, Bowmanville Site
• Beverley Tezak, Leader (Director), Quality, Patient Relations and
  Policy

                            QHN Fall Forum 2008
                                                   Background

• The overall aim for this project was to reduce narcotic
  medication errors to improve patient safety.
• Patient safety concerns related to narcotics
  administration arise due to:
   –   Large selection of narcotic products
   –   Look alike and sound alike names
   –   Packaging and labeling
   –   Infusion pumps and patient controlled analgesia
   –   Internal challenges (environment)
   –   Physical space challenges



                             QHN Fall Forum 2008
                                         QI Tools

•   “BETTER” Reporting System
•   Workflow Construction Charts
•   Colour Coded Risk Ranking Scales
•   Root Cause Analysis
•   Process Flow Mapping


                   QHN Fall Forum 2008
BETTER Reporting System




    QHN Fall Forum 2008
                         Workflow Construction Charts

              Current                             Potential Breakdown
              Process                                 in Process
MD or Nurse does Assessment                • Not done
                                           • Not recorded
                                           • Not reported
                                           • Not accurate
                Why                                      Harm Reduction
• Time constraints?                        • Education
• Forgot to record, distractions
• Education required to report
  accurately




                                   QHN Fall Forum 2008
                                          Coloured Coded
                                          Ranking Scales
                         High Risk                              Low Risk
                • High probability for error         • Low probability for error
                • Unsafe to patient                  • Low impact of the outcome
High Priority



                • Unsafe to Staff                    • Low impact staff and patient
                • High frequency of the occurrence   • Infrequency of occurrence Urgency
                • Urgency                            • Significant Impact
                • Significant Impact                 • Potential for harm
                • Potential for harm                 • Quick Win
                • Quick Win                          • Significant system impact
                • Significant system impact


                • High probability for error         • Low probability for error
                • Unsafe to patient                  • Low impact of the outcome
Low Priority




                • Unsafe to Staff                    • Low impact staff and patient
                • High Frequency of the occurrence   • Infrequency of occurrence Urgency
                • Not Urgent                         • Time consuming, complex process,
                • Won’t have significant impact         long term planning
                • Reduced potential for harm
                • Time consuming, complex process,
                  long term planning
Root Cause Analysis




  QHN Fall Forum 2008
Process Flow Mapping




   QHN Fall Forum 2008
Intended or Achieved
     Outcomes




  QHN Fall Forum 2008
                                           Key Success
                                        Factors/Enablers
• Teamwork, collaboration and an inter-professional approach
  to assessing narcotic administration.
• Following the implementation of the electronic good catch and
  actual event reporting system (BETTER) in June 2007, the
  number of reported medication incidents increased
  significantly as a result of a) education, b) ease of use of the
  system and c) an increased focus on patient safety.
• Ongoing monitoring of practices such as the end of shift
  narcotic medication counts, review of narcotic records and
  daily delivery of medications by pharmacy technicians
  resulted in early detection of narcotic medication incidents
  and increased frequency of reported of actual or potential
  errors.
• Leadership identified that patient safety is paramount and a
  review of staffing consideration and impacts was secondary.
                           QHN Fall Forum 2008
                             Potential or Actual
                                        Barriers
• Nursing staff initially felt the implementation
  of the independent double check was a
  punitive act that targeted this unit for making
  and reporting narcotic medication errors.
• Resistance to change was overcome through
  leadership excellence in maintaining and
  sustaining gains throughout the year long
  change process.


                    QHN Fall Forum 2008
                                   Lessons Learned

• sustainability for practice change, leadership
  engagement, and supporting staff throughout the
  process of change were all essential
• engaging staff during change management guides
  greater understanding by providing them with the
  results of literature reviews for best practice, including
  ISMP alerts/bulletins and the safety literature
• policy and procedure changes must reflect evidence
  and best practices
• ongoing discussions and meetings with staff kept them
  informed of updates and methods for maintaining and
  sustaining the change.
                        QHN Fall Forum 2008
                                         Next Steps

• Nursing Professional Practice has committed
  to changing nursing practice across the
  organization for independent double check for
  high risk medications based on the positive
  results of this initiative.
• Further education rollout to nursing staff on
  changes to the medication administration
  policies and procedures will be ongoing.

                   QHN Fall Forum 2008
Confidence, like art, never comes from
 having all the answers; it comes from
 being open to all of the answers
               Earl Gray Stevens

If we always look back, we lose sight of
   what’s ahead
                Justin Sims
                  QHN Fall Forum 2008
             Contact Information

            Pat Dingman,
            Clinical Leader,
     Post Acute Specialty Services,
           Bowmanville Site
    pdingman@lakeridgehealth.on.ca

             Denise Lamont,
    Quality Coordinator of Clinical Data
for Post Acute Specialty Services Program
     dlamont@lakeridgehealth.on.ca


               QHN Fall Forum 2008

								
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