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Heparin Documentation Improvement to Safely Manage Heparin Infusions Venus Manuel MSN, RN, PCCN; Jay Morrison MSN, RN, CPPS Vanderbilt Medical Center- Nashville, TN Background • • • • Figure 1 Heparin Documentation Conclusions • Nursing documentation of intravenous (IV) heparin infusion dose/hold is essential for patient safety. Barcode electronic medication administration system is used when administering medications. Bar code system is not currently available for continuous IV infusion doses such as heparin. Based on Physician feedback, dose documentation provided the most value in decision making related to heparin management. • • • Aim Heparin documentation change has increased the accuracy of nursing documentation of heparin. Placing the intervention within the nurses documentation workflow yields an increase in documentation. Targeted education and leadership rounding further increased compliance and adoption of practice change compared to integration with the workflow alone. Heparin dose documentation is now exported to an electronic heparin dashboard that physicians/providers can easily access (Figure 2). FIGURE 2 Heparin Dashboard To increase documentation of IV Heparin Administration (volume and dose) in the electronic nursing documentation system. Methods Identification of Problem • Adverse patient events that involved heparin infusions reviewed. • Heparin volume infusion documented every 4 hours, but does not reflect exact heparin dose administered – starts, stops, or holds. • Nursing electronic documentation system did not provide a standard location for nurses to document heparin IV holds or stops. New Process Implementation • Method developed to document heparin IV doses & holds (Figure 1). • Targeted education on new process • Audits and rounding performed daily for first month of implementation with immediate feedback to nursing staff • Implemented October 30th 2012 Settings • 2 cardiovascular step-down units implemented the new process, received detailed education and leadership rounding • All other adult Inpatient units had access to the intervention within their documentation workflow without specific education or leadership rounding TEMPLATE DESIGN © 2008 www.PosterPresentations.com Results .