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MPSC 2010 Annual Conference Solution Submission
Extra! Extra! Read All About It: How Interdisciplinary Teamwork
Saved the Day and the Baby!
Organization Name: Peninsula Regional
Medical Center
Regina Kundell
Contact Person:
E-Mail:
[email protected]
Type:
Acute Care Hospital
Title:
Dir, Women’s and Children’s
Services
410.543.7502
Phone:
IDENTIFICATION:
Current national publicity detailing life-threatening heparin errors in NICUs have brought
attention to the need to address this drug with urgency as a specific, high-risk, potentially deadly
medication. Despite recent, high profile fatal and near-fatal events, heparin errors continue.
NICU heparin errors nationwide have affected 17 infants in Corpus Christi, Texas, 6 infants in
Indianapolis, Indiana and 3 infants in Los Angeles, California-several of which had fatal
outcomes. Root cause analyses often implicate several causative factors, which include
calculation errors, unfamiliar heparin concentrations, failed verification processes and
inconclusive industry standards. Calculation errors and unfamiliar concentrations have occurred
when facilities that normally use heparin in 1,000 units/mL vials may only be able to purchase
heparin in 10,000 units/mL vials, thus changing compounding procedures. Verification
processes often fail for a variety of reasons, including: inadequate staffing, training or
documentation of compounding; environmental factors; confirmation bias or simple human
error. Inconclusive industry standards include heparin shortages, various protocols utilized for
maintaining patency instead of standardized protocols, heparin storage and different
concentrations with look-alike vials and color-coding.
Our problem involved a recent “near miss” event. After ordering the umbilical venous catheter
maintenance fluid using standardized pre-printed order sheets with the appropriate dose, rate and
delivery method, an IV bag of fluid was delivered to the NICU. Because of the “high alert”
designation for heparin, two registered nurses (RNs) independently verified the IV fluid. The
label had the correct identification information, dosage and bar-coding. Red flags were raised
when the IV fluid bag was not in the usual 500 mL bag of D10W, but instead it was in a 250 mL
bag of D5W. This prompted further investigation which revealed a pre-mixed bag labeled with
red letters stating 25,000 units heparin (100 units/mL). Pre-mixed bags were not typical in the
NICU since our fluids are usually compounded by pharmacy using 500 mL of D10W with a
concentration of 0.5 units/mL heparin (250 units of heparin). This was a potential 200 times
overdose of heparin.
Baseline data demonstrated no significant history of reported heparin errors in the neonatal
population at PRMC.
MPSC 2010 Annual Conference Solution Submission
PROCESS:
After performing the high-risk medication independent verification, the process began with our
staff nurses utilizing the TeamSTEPPS tool referred to as “Stop the Line”-encouraged by our
Leadership and engrained in our neonatal safety culture. The charge nurse then called the
Director of the Pharmacy Department, the Clinical Manager, the Clinical Nurse Specialist and
the Director of Women’s and Children’s Services. The IV fluid bag was sent to the Pharmacy
Department so that the Director of Pharmacy could investigate the incident. At first, the IV room
did not recall preparing anything for the NICU and were shocked about the possible occurrence.
A medication incident report was completed and sent to Risk Management that day. At the
earliest opportunity, Risk Management, the Directors from Pharmacy and Women’s and
Children’s Services initiated a Root Cause Analysis (RCA) and developed an action plan.
Because of the potential catastrophic nature of the near miss, the action plan was put forth
immediately.
The Pharmacy Department identified the breaks in the process using tools provided by Risk
Management and Process Improvement.
SOLUTION:
The solution was developed after walking through the entire medication process from initiation
of orders to sending the completed order to the unit. Several opportunities for improvement were
discovered. The first hurdle was differentiating neonatal and pediatric heparin orders from adult
orders. Our previous system did not discern this significant difference. Once this process was
fixed, the labeling system was investigated. The old process generated all patient labels from the
same printer. Now, neonatal and pediatric labels have their own printer situated away from the
adult label printer. In addition, neonatal and pediatric labels have been color-coded a bright
yellow to differentiate them from adult labels.
Because of this process change, there is now heightened awareness in both the Pharmacy and the
NICU. An added benefit from this process change is a safer Pediatric Unit, since their labels are
now separated and color-coded, as well. Included in the verification process is a checklist that
requires the Pharmacist to document the actual verification with the technician. This provides
written documentation of each step in the process.
Staff has been educated to fill out an occurrence report for any IV medication or IV fluid sent to
NICU or Pediatrics that has a white label instead of the bright yellow label. These are forwarded
to Risk Management for tracking of the RCA process compliance.
Pharmacy and Nursing Departments have been encouraged to report “near misses” with an
assurance that we function in a “just culture” and in a culture of transparency. The Maryland
Patient Safety Center is an excellent forum to discuss empowerment, so that flawed processes
can be fixed in a non-punitive environment.
MPSC 2010 Annual Conference Solution Submission
Celebrating our success will help maintain and sustain this process change. The two RNs
received letters of recognition from Peggy Naleppa, CEO of PRMC, letters of commendation
from the Board of Directors at PRMC and an article in our weekly newsletter highlighted the
proactive approach to near miss and actual error reporting. Also, no one involved was
terminated for this incident. Most importantly, a newborn baby’s life was saved.
OUTCOMES:
At this time, our results include anecdotal reports of “an additional layer of safety” important for
our neonatal and pediatric population, as well as confidence that each and every front-line
member of the team is empowered to initiate and utilize valuable process changes.
Nursing staff also indicate a feeling of confidence when they see the bright yellow label. The
new label provides pharmacy and nursing staff with heightened awareness regarding safety in
this patient population.
Staff expressed their desire to be kept informed about the resolution of occurrence reporting.
There is still a level of distrust that near miss and actual occurrence reports may lead to penalty.
Staff believe these reports are kept in their personnel file or held against them in some punitive
way. We would like this forum to be our first step towards the transparency that has become an
integral part of our hospital mission statement. In this way, we can demonstrate that reporting
near misses is in fact not punitive, but proactive in the continuing goal for process improvement
and patient safety.
Future implications include continued monitoring of the new process, identifying any potential
hurdles and implementing this in other departments where medication is delivered to the
neonatal or pediatric population, such as the OR and the ED. Another suggestion, which came
from a member of the Vermont Oxford Network, included further stratification by weight and
age. At this time, only IV medications and IV fluids are generated through this system.
Another step could include all PO/PR medications being identified through yellow labeling.
This potentially tragic near-miss has taught us valuable lessons about safe medication delivery,
process changes and speaking up even if we may be wrong. A culture of safety demands that
front line staff be congratulated for stopping the line, taking time out and speaking up for patient
well-being.