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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