Download Patient Safety

Department of Internal Medicine
Faculty of Medicine
Prince of Songkla University
Patient Safety
Quality Assurance Report: 30th November 2007
Department of Internal Medicine
Patient Safety project
Patient Safety in
critically ill patients
• Self extubation
Patient Safety in
cancer patients
• Oncology nurse
driven
chemotherapy
Patient Safety in
Critically ill patients
Prevention of self extubation
in medical ICU
Patient Safety
IMPACT
Number of medical ICU admission and
intubation : 2544 - present
Self extubation rate in medical ICU:
Before intervention
Why is self extubation important?
Risk of
airway
injury
Risk of
aspiration
and VAP
Increased
ICU
mortality
Self
extubation
Increased
ventilator
day
Increased
treatment
cost
Increased
ICU stay
Why is self extubation important?
Self extubation
ICU performance
benchmark
Must be zero
incidence
How could self extubation be
reduced?
ET-tube
strapping
technique
Patients
restrain
Relatives
education
sedation
Reduction of self extubation
Patient Safety
LITERATURE REVIEW
Sedation: Current Issues
Without a means to
objectively titrate
the level of sedation,
patients may be:
Over-sedated
Under-sedated
• increased drug costs
• delayed weaning
• increased ICU length of stay
• increased testing
• anxiety and agitation
• awareness and recall
• post-traumatic stress disorder
• increased adverse events
• increased use of paralytics
Daily interruption of sedative infusion in
critically ill patients undergoing
mechanical ventilation
Kress. NEJM 2000.
Effect of nurse-implemented sedation
protocol on the incidence of ventilatorassociated pneumonia
Quenot. CCM 2007.
Effect of nurse-implemented sedation
protocol on the incidence of ventilatorassociated pneumonia
Quenot. CCM 2007.
Sedation Use Recommendations
• Lorazepam is recommended for sedation of most patients via
intermittant IV or continuous infusion (Grade=B)
• Triglyceride levels should be monitored after two days of propofol
infusion (Grade=B)
• Use of sedation guidelines, an algorithm
or a protocol is recommended.
(Grade=B)
Jacobi J. Crit Care Med 2002; 30(1): 119-142.
Sedation protocol production
intensivist
Critical
care nurse
Agents
Mixture
Dosage
Morphine and
Midazolam (M&M)
combination
(First line agent)
Morphine 60
mg +
Midazolam 30
mg + NSS 60 ml
Morphine
Morphine 60 mg continuous drip 1-5 -for pain control only
+ NSS 60 ml
ml/hr and 1-3 m iv -as above
prn.
Midazolam
Midazolam 30
mg + NSS 60 ml
continuous drip 120 ml/hr
-only for sedation
Fentanyl
Fentanyl 500
mcg + NSS 50
ml
continuous drip 0.5
– 5 ml/hr
-second line agent for
Proprofol
Proprofol 200
mg
continuous drip 10- -second line agent for
150 ml/hr and 10- sedation
30 mg iv prn.
-check CPK and
Triglyceride level if use
longer than 5 days
-no analgesic effect at
all
loading 2-3 ml iv
then continuous
drip 1-20 ml/hr
and 1-3 ml iv prn.
Precaution
-prolonged effect in
renal dysfunction
-beware of seizure in
renal dysfunction due to
accumulation of active
metabolite of Morphine
pain control in renal
failure patients
4
3
Score
Description
7
Dangerous
agitation
6
Very agitated
Does not clam despite frequent verbal
reminding of limit, require physical restraints,
biting ETT
5
Agitated
Anxious or mildly agitated, attempt to sit up,
calm down to verbal instruction
Light
Sedation
(Default)
Calm and
cooperative
Sedated
2
Moderate
sedation
Very sedated
1
Heavy
sedation
Unrousable
Definition
Pulling at ET tube, trying to remove
catheters, climbing over bedrail, striking to
staff, thrashing side by side
Calm, awakening easily, follows command
Difficult to arouse, awake or eye open to
verbal stimuli or gentle shaking but drift off
again, follow simple command
Arouses to physical stimuli but does not
communicate of follow commands, may move
spontaneously, eye close
Minimal or no response to noxious stimuli,
does not communicate or follow commands,
weak cough on suction
แพทย์สง่ ั ระด ับ Sedation ที่
ต้องการ
เริม
่ ให้ยา Bolus injection และ
ให้ยาในระด ับตา่ ทีส
่ ด
ุ ตาม
guideline
ทดสอบระด ับ Sedation ของผูป
้ ่ วยทุก 30
้ 1-2 ml/hr จนได้ระด ับที่
นาที และปร ับยาขึน
ต้องการ
ึ ต ัวทุก
ประเมินความรูส
้ ก
1 ชว่ ั โมง
ระด ับ Sedation
มากกว่าทีต
่ อ
้ งการ
ลดขนาดยาลงครึง่ หนึง่ หรือ
หยุดการให้ยา
ระด ับ Sedation อยู่
ในระด ับทีต
่ อ
้ งการ
ระด ับ Sedation
น้อยกว่าทีต
่ อ
้ งการ
Bolus ยา และเพิม
่ ขนาดยา
อีก 1-2 ml/hr
Patient Safety
OUTCOME
Self extubation rate in medical ICU
intervention
Benchmarking
Patient Safety
LEARNING
Learning
• Sedation protocol is effective to prevent self
extubation in medical ICU.
• Sedation protocol did not increase ventilator
day and risk of VAP.
• The collaborate of critical care nurse and
intensivist is the key of success.
• The incidence of extubation could possible
reach to ZERO.
Learning
• We should be increase awareness and
alertness in isolated room patients.
• During period of sedation interruption,
critical care nurse must pay more attention to
the patients in order to prevent self
extubation.
• This protocol should be implemented in all
ventilator care unit.
Patient Safety in cancer
patients
Oncology nurse driven
chemotherapy
Patient Safety
IMPACT
Number of cancer patients in
medicine department: 2550
Medical error in
chemotherapeutic patients
• Inaccurate dose and drug
• Wrong patients
• Leakage of chemotherapy during
injection
• No medical advice postchemotherapy
Why chemotherapy error is
important?
life threatening
complication
Morbidity
Ineffective of
treatment
Poor
treatment
outcome
Safety in chemotherapy injection
Check
patient
label
Check
drug
and
dosage
Chemo
thera
peutic
unit
Oncology
nurse
No error in
chemotherapy given
Amended
injection
technique
Oncology nurse: job description
• Give chemotherapy to hospitalized
medical oncology patients
• Give medical advice for cancer patients
• Instruction and sharing the knowledge
of caring in cancer patient to ward
nurses
Patient Safety
OUTCOME
Number of patients : Jan - Oct 07
N
Total IPD cases
Average IPD cases/day
2,329
7.8
Total OPD cases
5,280
Average OPD cases/day
17.5
Lagging indicators
N
Inaccurate dose and drug
0
Wrong patients
0
Leakage of chemotherapy during injection
0
Medical advice postchemotherapy
100
ภาควิชาและมูลค่ าทีม่ ีการยกเลิกหลังเตรียมยา
(มกราคม – มิถุนายน 2550)
35,000.00
30,000.00
25,000.00
20,000.00
15,000.00
10,000.00
5,000.00
0.00
มูลค่า
ENT
กุม ารเวช
ศาสตร์
ศัลยศาสตร์
สูต-ิ นรีเวช
อายุรศาสตร์
2,318.50
10,068.62
29,561.40
34,685.74
7,259.02
Injection technique
Old fashion
Amended technique
• Scalp vein catheter
insertion
• IV push of
chemotherapy
• MEDICUT® insertion
• Extension tube connection
• IV push of chemotherapy
Patient Safety
LEARNING
Learning
• New infusion technique is safe and simple.
• Oncology nurse should be implemented in all
cases of chemotherapy patients.
• New process may be decrease unused drug.
THANK YOU