Download EP5.2.2 Renal Transplant Council Meeting Minutes

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KIDNEY TRANSPLANT COUNCIL
Meeting Date: July 16, 2014
7:45 am – 9:00am – CR-1 SFDB
Co-Chairs: Margaret Fitzsimmons & Kim Lawrence
Facilitator: Gemma Seidl
MINUTES
COMMENTS/DISCUSSION/
RECOMMENDATIONS/MOTIONS
(AIM)
TOPIC / AGENDA ITEM
WELCOME/INTRODUCTIONS
REFLECTION
ATTENDANCE
REVIEW MINUTES OF LAST
MEETING
PHARMACY UPDATE
Maggie opened the meeting at 7:52 a.m. and welcomed everyone. She
introduced our new attendees, Loman Poarch (DSU nights), Brooke Baitch
(ICU days), and Luke (Joseph) Coleongco (MICU nights).
Vivian Norman passed out individual reflections from Meditations from the
Heart, and each person read theirs out loud.
See below
Minutes of the May 21st meeting were sent electronically by Kim Lawrence
and accepted as written.
Peter Hosseinpour related the medication events and adverse drug reactions
since the last meeting. There were six med events and two drug reactions.
Peter noted that five of the med events occurred before the June 1, 2014
MediTech upgrade, and one med event was caused by the MediTech upgrade.
Med Events:
1. Severity 0, MICU. Drug: DDAVP
This was a dispensing issue related to a pre-med for a kidney biopsy.
The pharmacist dispensed the drug in a syringe as straight drug. The
drug is typically diluted in 50 ml of NS and dispensed as an IVPB.
The nurse noticed the error and requested the drug be prepared as an
IVPB. This lead to a delay in doing the procedure. The orders may
have been misinterpreted by the pharmacist because it was typed as
“DDAVP 24 MCG IV.”
2. Severity 1, DSU. Drug: Cellcept IV
This was a missed dose. The medication was on hold pending the
placement of an enteral tube. When the enteral tube was not placed,
APPROVALS/
ACTIONS
(Plan)
RESPONSIBLE
PARTY /
FOLLOW UP
(Do-Check-Act)
Maggie
Fitzsimmons
Vivian Norman
Maggie
Fitzsimmons
Peter
Hosseinpour
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TOPIC / AGENDA ITEM
COMMENTS/DISCUSSION/
RECOMMENDATIONS/MOTIONS
(AIM)
APPROVALS/
ACTIONS
(Plan)
RESPONSIBLE
PARTY /
FOLLOW UP
(Do-Check-Act)
the order was restarted at 21:39. Because it was restarted after 21:00,
the computer assigned a due time of 9:00 a.m. the next day. The night
nurse gave the drug that night but “stole” the 9:00 a.m. dose when
he/she charted on the eMAR. As a result, the 9:00 a.m. dose did NOT
pink up and was thus missed.
3. Severity 1, Med-Tele. Drug: Cyclosporin suspension
This was a dispensing error. The drug comes in a bulk bottle, and the
bottle did not have an expiration sticker on it as is required.
4. Severity 1, DSU. Drug: Prograf
This was an order entry issue by the Pharmacy. The pharmacist
applied the medication slider to this drug in error. This resulted in a
dose being given at 15:00 vs. 21:00. The 21:00 dose was held, and
drug levels were stable.
5. Severity 1, OR/PACU. Drug: Heparin infusion
The issue here was that the drug was labeled incorrectly. It appears
that the anesthesiologist mixed up a bag of Heparin but did not label
the bag correctly (i.e., hard to read the concentration, no prep date, no
expiration date, etc.)
6. (Under the new MediTech system) Severity 2, Med-Tele.
Drug: Valcyte/Bactrim
The issue was missed doses due to a MediTech build error. Both
drugs were ordered to be given using the sig “Q48HR.” This sig did
not have time associated with it in MediTech; thus it never pinked up
for the nurse, and the doses were missed. The issue has been resolved.
Adverse Drug Reactions:
1. Severity 3, MICU. Drug: Thymoglobulin
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TOPIC / AGENDA ITEM
COMMENTS/DISCUSSION/
RECOMMENDATIONS/MOTIONS
(AIM)
APPROVALS/
ACTIONS
(Plan)
RESPONSIBLE
PARTY /
FOLLOW UP
(Do-Check-Act)
Reaction: Head/neck pain. Chest pain, burning up spine.
Treatment: Hydrocortisone, drug stopped, Morphine, EKG. No
permanent harm.
2. Severity 3, ICU. Drug: Rituxan
Reaction: Swollen jaw, chest pressure, itching, restlessness.
LAB UPDATE
DATA SCORECARD/ACTIVITY
NEW BUSINESS
Treatment: Drug stopped, Benadryl, Hydrocortisone, MD notified.
Drug was infused at a slower rate once reaction cleared. No
permanent harm.
Sheila reported that there was only one lab update since the last meeting, and it
was last week. We made the turnaround time in 50 minutes with a transplant
patient. The patient went to MICU, and the nurse there was not a transplant
nurse. The labs on the pre-transplant patient were delayed in getting to the lab.
The usual transplant sticker wasn’t placed on the lab bag, so the patient was
not identified as a transplant patient. Lab was not notified prior to the Labs
being drawn that we had a patient being ready to be transplanted. Usually once
notified both Phlebotomy and Processing are alerted which makes the process
go smoother and faster.
Kim advised that the data scorecard information gets reported to Dialysis and
Transplant Committee, and there were no failures in 2014 until the month of
May. There was one patient, which equates to a 25% failure related to the
documentation of ABO type prior to listing the patient in UNOS. The process
for ABO documentations was reviewed with all RNs in transplant. The
correction action for this was, 2nd ABO verification will now occur in
Transplant Committee by an RN when the patient is ready to be listed in
UNOs for Transplant candidacy.
Completed forms for patient follow up are not available for first quarter.
There is usually a delay in UNOS in getting stats uploaded.
Maggie spoke about department placement for renal transplant patients and
went over the algorithm. It has been disseminated to all departments, and
Wendy will be presenting it at the Nurses Leadership Meeting next week.
Wendy noted that MediTech will be updated to automatically capture
information for a renal transplant patient’s history. Pharmacy will monitor
Sheila Brown
2nd ABO
verification will
now occur in
Transplant
Committee by an
RN when the
patient is ready to
be listed in UNOs
for Transplant
candidacy.
Kim Lawrence
Maggie
Fitzsimmons/Kim
Lawrence/Wendy
Escobedo
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TOPIC / AGENDA ITEM
COMMENTS/DISCUSSION/
RECOMMENDATIONS/MOTIONS
(AIM)
APPROVALS/
ACTIONS
(Plan)
RESPONSIBLE
PARTY /
FOLLOW UP
(Do-Check-Act)
high-risk patients for any possible immuno-suppressant medications. If a DSU
bed isn’t available, the patient will be upgraded to MICU.
Kim is doing in-services in DSU. The first in-service was called
Fundamentals of Kidney Transplant. She is keeping a check-off list of who
has been educated, with the goal of educating everyone on the list. There was
a good turnout on July 11th. Night shift nurses need more training. The next
in-service will be on Kidney Biopsy. Vivian will schedule more in-services.
Dr. Ruzics will speak for about the first hour and a half at the transplant class
on August 15th.
Dr. Ruzics reported that PR had distributed copies of a Phys-Link article to
physicians and management regarding important information on transplant
patients and what St. Joseph is up to. We have been focusing on one-year graft
survival. When a person hits the 3-year mark, it really is a successful
transplantation milestone. Transplants are cheaper than dialysis, but the
Federal government is on the hook for dialysis for $40B for whoever needs it.
St. Joseph had the highest 30-year graft survival in California and exceeds the
national one-year survival rates.
Wendy expressed a need for help on the annual Rose Ceremony. We are
looking at October 24th in the Healing Garden from 10:00 a.m. to 12:00 Noon.
We are waiting to hear back from One Legacy about their availability.
ADJOURNMENT
Today’s meeting adjourned at 8:40 a.m.
 Next meeting: September 17 – CR-1 SFDB
 Reflection: Sheila Brown
Recorded by:
Pepper Harris, Executive Secretary
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MEMBERS /
CREDENTIAL
TITLE
ROLE/SPECIALTY
Date
1/15/14
CR-7
Date
3/18/14
CR-7
Date
5/21/14
CR-1
Date
7/16/14
CR-1
Acevedo-Cosio, Lilia
RN
Cardiac Renal
A
Asano, Beth
Clinical Dietician
MD
A
Baitch, Brooke
RN
DSU
X
Boose-Shutes, Linda
RN BSN
Manager, DSU
X
Brown, Sheila
Supervisor
Lab
X
Coleongo, Luke
RN
MICU
X
Escobedo, Wendy
Clinical Manager
Renal Transplant Center
A
Faulkner, Judith
Dietician
RD
X
Fitzsimmons, Maggie
DSU
RN
X
Gull, Paula
RNP
TX Renal Center
A
Garakian, Margie
Case Manager
Renal Transplant Center
A
Hosseinpour, Peter
Renal Trans. Specialist
Pharmacy
X
Lawrence, Kim
CC Transplant
Renal Transplant Center
X
Messana, Anthony, RN Exec. Dir
Renal Center
X
Munoz, Paz, RN BSN
CN III
Critical Care
X
Norman, Vivian, RN
Educator
Critical Care
X
O’Callaghan, Mary
Social Worker
Renal Transplant
X
Oneill, Jungmi
RN
Pulmonary Renal
A
Ruzics, Ervin MD
Medical Director
Renal Transplant Program
X
Sanchez, Esperanza
Social Worker
Pulmonary Renal
A
Satterfield, Mary
Chem. Supervisor
Lab
A
Saunders, Erin
RN
MICU
Seidl, Gemma
Manager
Critical Care
Sousa, Lucy
RN
Weil, Marya, RN, BSN Transplant Coordinator
A
X
Renal Transplant Center
X
Date
9/17/14
CR-1
Date
11/19/14
CR-1