Here are some questions from our live presentation:
Q: Why did you eliminate oral ketorolac?
Q: Do you stock IV epinephrine in your cath lab other than what is inside the crash cart?
Q: Please explain further your process for fentanyl patches (destruction/waste)
Q: What do you do on leadership rounds?
Q: Did you find certain drugs that were more likely to cause falls?
Q: How do you calculate medication errors and evaluate dispensing errors?
Q: What have you implemented to reduce inappropriate hydromorphone (Dilaudid) IV dosing?
Q: Who is on your Medication Safety Team/Committee? How often do you meet?
Q: Do you have a Medication Safety Scorecard, or are you aware of one? If so, what are the measures tracked on the scorecard? Are there goals/targets established for each of the measures?
Q: Regarding the errors-reduction strategy, what does it mean the fail safe & constraints and forcing function?
Q: Can you describe your process in how you were able to switch weights to kg only? We've run into some roadblocks with this.
02-02-201210:37 AM - last edited on 02-03-201209:04 AM by HeatherQ
Q: Why did you eliminate oral ketorolac?
Ketorolac does not differ substantially in cardiovascular risk from other traditional NSAIDs. However, it does differ significantly in that it confers greater gastrointestinal risk. (http://www.medicine.ox.ac.uk/bandolier/booth/painpag/nsae/nsae.html, accessed 2/1/2012)
Table 5: Relative risk of gastrointestinal complications with NSAIDs, relative to ibuprofen or non-use (shaded)
Drug
Case-control studies [12]
Cohort study [7]
Italian case-control [13]
Nonuse
1.0
Ibuprofen
1.0
1.0
2.1 (0.6 to 7.1)
Fenoprofen
1.6 (1.0 to 2.5)
3.1 (0.7 to 13)
Aspirin
1.6 (1.3 to 2.0)
Diclofenac
1.8 (1.4 to 2.3)
1.4 (0.7 to 2.6)
2.7 (1.5 to 4.8)
Sulindac
2.1 (1.6 to 2.7)
Diflusinal
2.2 (1.2 to 4.1)
Naproxen
2.2 (1.7 to 2.9)
1.4 (0.9 to 2.5)
4.3 (1.6 to 11.2)
Indomethacin
2.4 (1.9 to 3.1)
1.3 (0.7 to 2.3)
5.4 (1.6 to 18.9)
Tolmetin
3.0 (1.8 to 4.9)
Piroxicam
3.8 (2.7 to 5.2)
2.8 (1.8 to 4.4)
9.5 (6.5 to 13.8)
Ketoprofen
4.2 (2.7 to 6.4)
1.3 (0.7 to 2.6)
3.2 (0.9 to 11.9)
Azopropazone
9.2 (2.0 to 21)
4.1 (2.5 to 6.7)
Ketorolac
24.7( 9.6 to 63.5)
Note that the Italian case-control study (shaded) compares risk of gastrointestinal event with non-use, while the other two reports make the comparison with ibuprofen.
Q: Do you stock IV epinephrine in your cath lab other than what is inside the crash cart?
We do NOT stock epinephrine in our cath lab automated dispensing cabinets.
Q: Please explain further your process for fentanyl patches (destruction/waste)
According to the package insert, used patches should be folded so that the adhesive side of the patch adheres to itself, then the patch should be flushed down the toilet immediately upon removal. However, our hospital policy requires all narcotic waste to be witnessed by another nurse. So we prepared the attached policy.
Q: What do you do on leadership rounds?
Usually nurses will approach me and inform me of something that happened on their unit. It could be a pump issue or a vague order, or a resident that asked the nurse a question, an infection control issue, etc.
After the initial encounter, I look to see if there are any unsecured medications in the nursing unit. I check to see if the med room is locked. I then enter the med room and look for odd things. I then speak to nurses to see if they have had any issues with pharmacy – any delays, etc. I then go into patient rooms and ask questions about pain relief or if they have any questions about their medications. I ask if the nurse educated them on any new medications that they started in the hospital.
Q: Did you find certain drugs that were more likely to cause falls?
We keep detailed information on our patient falls in the rehabilitation hospital. Most occur when the patient is trying to go to the bathroom. So we encourage patients to “call and not fall.” The patients also receive a scripted orientation about falls and the importance of avoiding falls. As far as the medications are concerned, any centrally acting (antipsychotic, antidepressant, anxiolytics, antiepileptic) or antihypertensives have the potential of causing falls. If a new medication is started, the nurses educate the patient. In addition, the nurses will ask and assist the patient to the bathroom before the patient sleeps.
We dose limit zolpidem, temazepam, and lorazepam.
Monane M, Avorn J. Medications and Falls. Causation, correlation and convention. Clin Geriatr Med
1996 12:847-858.
Q: How do you calculate medication errors and evaluate dispensing errors?
Medication errors are under reported in almost every hospital. We encourage our providers to report. We have informed the pharmacists that they have to report and that the number will be discussed in their annual performance reviews. If I am made aware of an error, I report it. We average 35 per month. I can easily say with the delays in administration or dispensing, there should be 35 per day.
Q: What have you implemented to reduce inappropriate hydromorphone (Dilaudid) IV dosing?
That is a difficult question. It all goes back to the initial order by the physician. We built order sentences that physicians pick from the recommended doses/frequencies. However, I find that most of our physicians prefer to prescribe morphine.
Q: Who is on your Medication Safety Team/Committee? How often do you meet?
We meet monthly. We have residents, nurses, pharmacists, risk quality and the patient safety officer attending.
Q: Do you have a Medication Safety Scorecard, or are you aware of one? If so, what are the measures tracked on the scorecard? Are there goals/targets established for each of the measures?
Yes, I report on the error reporting rate. This number is very different than the total errors that occur in the hospital. Most hospitals under report. I also report monthly on the number of medication errors reported, ADRs, clinical interventions, anticoagulation ADEs (with a breakdown of heparin infusions and warfarin), rehabilitation chart reviews, total medication orders, total doses dispensed, total digoxin levels above 2, total percentage of successful bar-coding per area, number of falls in the rehab hospital. I report on the number and rate of the following for the smart pump: total infusions with smart pump, total using the guardrails, total hard limit alerts, ten-fold or greater alerts, and soft dollars saved per quarter. I have set goals for the smart infusion device. I decided on these targets after a discussion with quality and risk. Software compliance of using guardrails – 100%, patient ID compliance 95%, hard limit alerts 500, ten-fold or greater alerts – zero.
Q: Regarding the errors-reduction strategy, what does it mean the fail safe & constraints and forcing function?
Forcing functions are powerful and effective tools. They involve designing a process so that errors are impossible or difficult to make. Examples include removing potassium chloride for injection from all nursing units, eliminating alteplase from the ED so that there can be no errors in reconstituting and administering the wrong amount of drug.
Forcing functions are features that restrict the way in which tasks may be performed. Another example is using oral syringes that are not capable of connecting to the IV lines for all liquid medications.
Q: Can you describe your process in how you were able to switch weights to kg only? We've run into some roadblocks with this.
I guess it depends on the type of scale. With the scales we have, it was possible to lock them to kg only.
