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Intervention A multi-disciplinary committee investigated possible solutions and leading practice change strategies for medication safety in the PACU.

Working group – 2 pharmacists, 6 front line nurses, 2 charge nurses, 1 nurse educator

Process Map – Developed based on current process. Used to facilitate discussion about high risk practices that users had become desensitized to within the current system. (see below)

RATIONALE  Due to frequency and complexity of medication administration in high acuity patients; the PACU is a high risk environment for medication errors. Multi-dosing from a single narcotic syringe is prevalent. In addition, a safe work environment for staff members with chemical dependencies needs to be promoted. Current studies report 7% of medication administration events are errors1(in an intensive care setting); 6% of those will cause serious harm to patients2. This suggests that 1 in 100 patients are harmed by medication errors in our PACUs.

DESCRIPTION  

SELECTED  REFERENCES  1 –Hicks, R. W., Becker, S. C., Windle, P. E., & Krenzischek, D. A. (2007). Medication errors in the PACU. Journal of perianesthesia nursing. 22(6), 413–419. 2 – Chapuis, C., Roustit, M., Bal, G., Schwebel, C., Pansu, P., David-Tchouda, S., Foroni, L., et al. (2010). Automated drug dispensing system reduces medication errors in an intensive care setting. Critical care medicine, 38(12), 2275–2281 3 –Brooke, J.SUS – a quick and dirty usability scale. Digital equipment corporation. 1986. Accessed: 17-Jan-2012 from: http://www.measuringusability.com/sus.php

ACKNOWLEDGEMENTS  

Anne Marie El-Kahlout and Michelle Stevenson for tireless efforts producing and managing the stock of pre-filled syringes during the study.  Silvia Katsaros, Cathy Mezzalira, Amanda Staples, Danielle Lloyd, Michelle Marcoux, Claudia Gogishvilli, and Christine Body for their help with students, operationalizing the study and coping with day-to-day issues. Lehanna Thebane and Emmy Cheng for help with statistical elements.  Toni Tidy for administrative support and advocacy.

Factors Encouraging Workarounds – Staff identified aspects of their work environment they felt forced workarounds •  High frequency medication administration ( q15-30 mins) •  Wide dose ranges written by prescribers ( 2-15mg q3h PRN) •  Patients with acute medical issues and/or unpredictable medication

needs due to –  unstable or acutely ill patients –  chronic pain histories –  want to “be prepared” and anticipate based on clinical judgment and

previous experience

•  Isolation of, and proximity of medication room and AcuDose •  Low staffing levels on weekends/evenings increases time stressors

Solution development – developed based on current process. Users proposed, and jointly identified areas for improvement. 1)  Access to AcuDose

i.  Additional AcuDose machine, ii.  Move AcuDose into closer proximity of nursing work areas

2)   Narcotics left unattended or unlabeled i.  Make/buy unit dose prefilled syringes (PFS)

morphine (1mg/1ml, 2mg,3mg) HYDROmorphone (0.2mg/1ml, 0.4mg)

ii.  Secure bedside medication storage

Data collection plan – Agreement with system users about how success or failure is assessed: Retrospective chart review, nurse surveys, direct observation of practice & workload measures Nurse Survey – All respondents (100%) wanted to continue with narcotic PFSs; of them 39% believed higher dose PFS were needed. System Usability Scale3(worst=0, best 100) - This is a standardized 10 question survey that is used to quantitatively contrast system usability. Nurses completed surveys before ( SUS Score =78.1) and after (SUS Score = 75) the PFS pilot. No significant difference could be shown between the two systems.

STEPS  TAKEN  CONT.  

 Eric  JP  Romeril  B.Sc.Pharm.1,  Melanie  MacInnis  Pharm.D.1,2,  Leslie  Gauthier  R.N.  M.Sc.1,3,  Leslie  Gillies  R.N.  M.Ed.1,3,    Marianne  Kampf    R.N.1,    James  Paul  M.D.  FRCPC1,2        

 

INTERDISCIPLINARY  MEDICATION  SAFETY  INITIATIVE  TO  IMPROVE  NARCOTIC  USE  PRACTICES    IN  A  POST  ANESTHESIA  CARE  UNIT  (PACU)    

Direct Observation - The intervention completely eliminated narcotic waste documentation problems, and showed a trend towards reduction of patient’s average pain score. Data collection was not of high quality, no definitive conclusions possible. Workload - It took 7 hours of Pharmacy technician time a week to manufacture the unit dose syringes. It is inefficient to produce unit dose package sizes, given the doses used per week. Chart Review - A retrospective chart review uncovered irregularities with medication dispensing and documentation from the automated dispensing cabinet; such that the integrity of signature chain was interrupted. Current state: The unit now has 2 AcuDoses, which are more accessible and stock unit dose vials of narcotic medications. Future direction of research could be using higher dose PFS.

EVALUATION  CONTINUED    

1)  Our initial solution was popular, but was more resource intensive than predicted & caused dispensing problems

2)  The PACU is a unique care environment, multi-disciplinary problem solving proved effective

3)  Longer implementation period was needed to resolve logistical, manufacturing & nurse education issues

IMPORTANCE    

Affilia.ons.      1=  Hamilton  Health  Sciences,  2=  McMaster  University,  DeGroote  School  of  Medicine,  Department  of  Anesthesia,    3=  McMaster  University,    School  of  Nursing  

STEPS  TAKEN  

EVALUATION