Download Oxytocin Deep Dive - Institute for Healthcare Improvement

Perinatal Improvement
Community
Oxytocin: High Alert Medication Deep Dive
Getting Started
Perinatal Improvement Community, 2010
Oxytocin Deep Dive
Background:
On August 9, 2007, oxytocin was designated as a high alert medication by the
Institute for Safe Medication Practices (ISMP)- see appendix. The use of oxytocin is
significant on L&D Units across the U.S. and concerns related to Perinatal harm and
liability led to the development of the IHI Oxytocin Bundles. Considerable concern
exists regarding the variation and the reliable administration of oxytocin.
This tool is currently being tested by the IHI Perinatal Improvement Community to
assist teams to evaluate the safety of their environment while oxytocin is
administered at a system level. The goal is to establish a system linkage with
structure/process/outcomes.
Supporting References:
1. JCAHO Standard MM.7.10 The organization develops processes for
managing high-risk or high-alert medications. JCAHO defines high-risk and
high-alert medications as medications involved in a high percentage of
medication errors or sentinel events and medications that carry a high risk for
abuse, error, or other adverse outcomes. JCAHO requires organizations to
identify high-risk and high-alert medications used within the organization.
National lists, as well as organization-specific data, on drug use should be used
for defining the drugs considered high risk or high alert by the organization. The
organization also must develop additional processes for selecting, procuring,
storing, ordering, transcribing, preparing, dispensing, administering, and
monitoring these high-risk and high-alert medications.
2. ISMP Alert, August 9, 2007. Oxytocin was named a high-alert medication in
2008. High alert medications require special safeguards to reduce the risk of
errors. This may include strategies like improving access to information about the
drug; limiting access; using auxiliary labels and automated alerts; standardizing
the ordering, storage, preparation and administration; and employing
redundancies such as automated or independent double checks when
necessary. Available for free download at http://www.ismp.org/Tools/highalertmedications.pdf
3. Simpson, Kathleen Rice. Measuring Perinatal Patient Safety: Review of Current
Methods. JOGNN. 35, 432-442. 2006.
4. The Deep Dive is intended to be repeated every six months- usually prior to
a face to face meeting to measure your progress.
1
Oxytocin Deep Dive
5. Steps in the Process
 Meet as a team to review the tool
 Identify a 2 week period to review the records of all patients who received
oxytocin (>37 weeks or term by ACOG definition)
 Review records with as much team participation as possible
 Collate results and share at a team meeting. Post to your team homepage
on the Extranet
 Identify your opportunities and relate this to your AIM for the Perinatal
Community
 Celebrate what you do well and share with the entire unit
 Schedule a meeting with Sue Gullo to review your results and next step if
needed [email protected]
 Insert results into your Meeting Storyboard (storyboard instructions and
materials will be sent out one month prior to in person meeting)
2
Oxytocin Deep Dive
Structure
Yes
No
N/A
1. Interdisciplinary Fetal Monitoring Education
2. Documentation tools consistent with NICD terminology
3.Weekly fetal monitoring strip and case reviews (or (#4)
4. Monthly fetal monitoring strip and case reviews
5. Standard mixture and policy for oxytocin
administration
6. One standard administration order set
7. If provider opts out of standard order set, system in
place to identify and address when standardized dosage
is not followed.
8. Team definition for tachysystole
9. Clinical algorithm for identification and management of
tachysystole
10. Clinical algorithm for management of
indeterminate/abnormal FHR patterns (NICHD 2009)
11. RN empowered to call cesarean team (not to
diagnose the need for cesarean, but to activate the team)
12. RN empowered to call neonatal team
13. Consistent handoff tool {SBAR, etc} specify
14. Informed Consent for oxytocin administration
15. Individual Provider data published about
induction/augmentation rates?
*The Faculty would also like the team to note specific individual provider/nurse
practice patterns while reviewing all records during the 2 weeks which may be used
internally to identify further opportunities to reliably deliver oxytocin.
Link to high alert medication
Link to Oxytocin Bundles
Structure Document Directions:
Interview at least 5 different people on the unit (Nurses, Physicians) to determine if
they all share the same yes/no answer on these questions. It will assist you in
identifying any gaps from policy/procedure to care delivery at the patient level.
Example: A nurse on weekends or nights may not have the same answer as a
nurse on the day shift during the week.
3
Oxytocin Deep Dive
Process
Yes
No
Explanations to support the process
questions
Careful Monitoring1. Appropriate level (high risk) based
electronic fetal monitoring (or IA) for fetal
heart rate and uterine activity while oxytocin
administered.(Per Perinatal Guidelines)
2. Oxytocin initiated as intended – no delay
in administration due to provider or nursing
response.
Timely Identification3. □Tachysystole identified and managed
according to protocol /algorithm
□Tachysystole identified and managed
according to team definition and standing
orders
High risk- every 15 minutes during the active phase of
the first stage of labor. Every 5 minutes during the
second stage of labor
4.
□ Indeterminate/abnormal FHR identified
Appropriate Interventions5. Oxytocin dose decreased or discontinued
during labor due to tachysystole?
6. Oxytocin dose decreased or discontinued
during labor due to FHR?
7. Oxytocin resumed after a decrease or
stop?
Note in this column if reassuring/normal
status always present.
8. Terbutaline administered?
9. Interventions needed?
10. Once labor was progressing, was
oxytocin discontinued?
Activation of Team Response
11. Documentation of physician notification
of change in dosage of oxytocin.
12. If requested, timely response by OB care
provider for bedside evaluation.
13. Escalation plan in place if needed and
documented.
14. Documentation of oxytocin dosage and
pattern of administration during handoff.
15. Day of week______________
16. Shift/Shifts care delivered__________
4
Was there a delay in initiation or during
administration due to provider unavailability,
nursing staffing, provider staffing issues?
If tachysystole was not present, please
make sure you note this in this column but
do not collect information on yes/no unless
it is present.
□ No tachysystole present
__________#times
__________#times
Decrease or stop related to the presence
of tachysystole or non-reassuring FHR.
Other?
Interventions may be change in position,
IV fluid bolus, and emergency cesarean.
Was oxytocin stopped when labor pattern
was effective?
If tachysystole or indeterminate/abnormal
FHR noted, was provider supportive of
decision to discontinue medication?
Opportunity to determine if patterns of
administration are standard or subject to
other influences.
Oxytocin Deep Dive
Outcomes (T=from Perinatal Trigger
Tool)*
1. (T1) Apgar <7 at 5 min
2. (T2) Admission to NICU
3. (T7) 3rd or 4th degree laceration
4. (T9) Blood Transfusion
5. (T18) Instrumented delivery
6. (T15) Excessive blood loss
7. (T16) Neonatal Injury (e.g. fractured
clavicle)
8. (T20) Cord gas < 7.20
9. (T22) Other Shoulder dystocia
10. Cesarean Section
Yes
No
Comments
.
*Identification of these triggers as an outcome in this tool is a different process than
the Global Trigger tool process. It does not include the assignment of harm (we will
explain this further as you move forward in the Community).
NOTES:
5