safe practices to decrease the inherent risk of high alert ......questions what is the process for...
TRANSCRIPT
Safe Practices to Decrease the Inherent Risk of
High Alert Medications
Meghan Duck RNC-OB MS CNS
Perinatal Outreach
UCSF Benioff Childrenrsquos Hospital
May 2018
An estimated 44000 - 98000 people die each year from medical errors in hospitals
ldquoThe equivalent of a jumbo jet crashing every dayrdquo
New studies have shown these numbers are increasing
Khon 2000 Wachter 2004
1999 IOM Report To Err is Human
Building a Safer Health System
To err is humanhellip
The health reporter for the Boston Globehellip
bull Betsy Lehman died from chemo overdose
Additionally
bull Willie King had the wrong leg amputated
bull Ben Kolb (8yrs old)
‒ died during minor surgery
‒ Drug mix up
Preventable Medical Errors ranked above Diabetes Alzheimerrsquos and Influenza
A 2016 follow-up to the IOM study by Johns Hopkins
researchers found medical errors were underestimated
bull medication errors rarr most common mistakes
bull harming ge 15 million people per year
bull ~ 400000 preventable drug-related injuries per year
HUGE PROBLEM
From 1999 to 2016 What happened
Even the besthellipCan make a mistake
Severe outcomes of medical errors
bull Unnecessary blood transfusionsbull Unnecessary cesarean birthbull Prolonged hospitalizationbull Intrapartum fetal deathbull Neonatal deathbull Maternal death
High Alert Medications
OxytocinMagnesiumEpidural infusionOpioidsHeparinInsulin
bull Well-restedfed
bull Highly confident
bull Highly motivated
Institute of Medicine
Some Background
1998 The Quality of Healthcare in America project
‒ Develop a strategy that will improve quality
‒ Review and synthesize literature
‒ Develop communication strategies
‒ Articulate framework of incentivesfoster accountability
‒ Identify factors that improve quality of care
‒ Develop research agenda
To errhellipis expensive
Medication errors cause temporary harm
Disability and death
The human costs are incalculable
The financial cost is estimated and very likely underestimated
bull ge $171 billion every year
bull Range found in literature
Most common reason for malpractice lawsuits
bull Average amount awarded by the courts is $31 million
HHS 2010
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
An estimated 44000 - 98000 people die each year from medical errors in hospitals
ldquoThe equivalent of a jumbo jet crashing every dayrdquo
New studies have shown these numbers are increasing
Khon 2000 Wachter 2004
1999 IOM Report To Err is Human
Building a Safer Health System
To err is humanhellip
The health reporter for the Boston Globehellip
bull Betsy Lehman died from chemo overdose
Additionally
bull Willie King had the wrong leg amputated
bull Ben Kolb (8yrs old)
‒ died during minor surgery
‒ Drug mix up
Preventable Medical Errors ranked above Diabetes Alzheimerrsquos and Influenza
A 2016 follow-up to the IOM study by Johns Hopkins
researchers found medical errors were underestimated
bull medication errors rarr most common mistakes
bull harming ge 15 million people per year
bull ~ 400000 preventable drug-related injuries per year
HUGE PROBLEM
From 1999 to 2016 What happened
Even the besthellipCan make a mistake
Severe outcomes of medical errors
bull Unnecessary blood transfusionsbull Unnecessary cesarean birthbull Prolonged hospitalizationbull Intrapartum fetal deathbull Neonatal deathbull Maternal death
High Alert Medications
OxytocinMagnesiumEpidural infusionOpioidsHeparinInsulin
bull Well-restedfed
bull Highly confident
bull Highly motivated
Institute of Medicine
Some Background
1998 The Quality of Healthcare in America project
‒ Develop a strategy that will improve quality
‒ Review and synthesize literature
‒ Develop communication strategies
‒ Articulate framework of incentivesfoster accountability
‒ Identify factors that improve quality of care
‒ Develop research agenda
To errhellipis expensive
Medication errors cause temporary harm
Disability and death
The human costs are incalculable
The financial cost is estimated and very likely underestimated
bull ge $171 billion every year
bull Range found in literature
Most common reason for malpractice lawsuits
bull Average amount awarded by the courts is $31 million
HHS 2010
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
To err is humanhellip
The health reporter for the Boston Globehellip
bull Betsy Lehman died from chemo overdose
Additionally
bull Willie King had the wrong leg amputated
bull Ben Kolb (8yrs old)
‒ died during minor surgery
‒ Drug mix up
Preventable Medical Errors ranked above Diabetes Alzheimerrsquos and Influenza
A 2016 follow-up to the IOM study by Johns Hopkins
researchers found medical errors were underestimated
bull medication errors rarr most common mistakes
bull harming ge 15 million people per year
bull ~ 400000 preventable drug-related injuries per year
HUGE PROBLEM
From 1999 to 2016 What happened
Even the besthellipCan make a mistake
Severe outcomes of medical errors
bull Unnecessary blood transfusionsbull Unnecessary cesarean birthbull Prolonged hospitalizationbull Intrapartum fetal deathbull Neonatal deathbull Maternal death
High Alert Medications
OxytocinMagnesiumEpidural infusionOpioidsHeparinInsulin
bull Well-restedfed
bull Highly confident
bull Highly motivated
Institute of Medicine
Some Background
1998 The Quality of Healthcare in America project
‒ Develop a strategy that will improve quality
‒ Review and synthesize literature
‒ Develop communication strategies
‒ Articulate framework of incentivesfoster accountability
‒ Identify factors that improve quality of care
‒ Develop research agenda
To errhellipis expensive
Medication errors cause temporary harm
Disability and death
The human costs are incalculable
The financial cost is estimated and very likely underestimated
bull ge $171 billion every year
bull Range found in literature
Most common reason for malpractice lawsuits
bull Average amount awarded by the courts is $31 million
HHS 2010
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Preventable Medical Errors ranked above Diabetes Alzheimerrsquos and Influenza
A 2016 follow-up to the IOM study by Johns Hopkins
researchers found medical errors were underestimated
bull medication errors rarr most common mistakes
bull harming ge 15 million people per year
bull ~ 400000 preventable drug-related injuries per year
HUGE PROBLEM
From 1999 to 2016 What happened
Even the besthellipCan make a mistake
Severe outcomes of medical errors
bull Unnecessary blood transfusionsbull Unnecessary cesarean birthbull Prolonged hospitalizationbull Intrapartum fetal deathbull Neonatal deathbull Maternal death
High Alert Medications
OxytocinMagnesiumEpidural infusionOpioidsHeparinInsulin
bull Well-restedfed
bull Highly confident
bull Highly motivated
Institute of Medicine
Some Background
1998 The Quality of Healthcare in America project
‒ Develop a strategy that will improve quality
‒ Review and synthesize literature
‒ Develop communication strategies
‒ Articulate framework of incentivesfoster accountability
‒ Identify factors that improve quality of care
‒ Develop research agenda
To errhellipis expensive
Medication errors cause temporary harm
Disability and death
The human costs are incalculable
The financial cost is estimated and very likely underestimated
bull ge $171 billion every year
bull Range found in literature
Most common reason for malpractice lawsuits
bull Average amount awarded by the courts is $31 million
HHS 2010
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
From 1999 to 2016 What happened
Even the besthellipCan make a mistake
Severe outcomes of medical errors
bull Unnecessary blood transfusionsbull Unnecessary cesarean birthbull Prolonged hospitalizationbull Intrapartum fetal deathbull Neonatal deathbull Maternal death
High Alert Medications
OxytocinMagnesiumEpidural infusionOpioidsHeparinInsulin
bull Well-restedfed
bull Highly confident
bull Highly motivated
Institute of Medicine
Some Background
1998 The Quality of Healthcare in America project
‒ Develop a strategy that will improve quality
‒ Review and synthesize literature
‒ Develop communication strategies
‒ Articulate framework of incentivesfoster accountability
‒ Identify factors that improve quality of care
‒ Develop research agenda
To errhellipis expensive
Medication errors cause temporary harm
Disability and death
The human costs are incalculable
The financial cost is estimated and very likely underestimated
bull ge $171 billion every year
bull Range found in literature
Most common reason for malpractice lawsuits
bull Average amount awarded by the courts is $31 million
HHS 2010
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Even the besthellipCan make a mistake
Severe outcomes of medical errors
bull Unnecessary blood transfusionsbull Unnecessary cesarean birthbull Prolonged hospitalizationbull Intrapartum fetal deathbull Neonatal deathbull Maternal death
High Alert Medications
OxytocinMagnesiumEpidural infusionOpioidsHeparinInsulin
bull Well-restedfed
bull Highly confident
bull Highly motivated
Institute of Medicine
Some Background
1998 The Quality of Healthcare in America project
‒ Develop a strategy that will improve quality
‒ Review and synthesize literature
‒ Develop communication strategies
‒ Articulate framework of incentivesfoster accountability
‒ Identify factors that improve quality of care
‒ Develop research agenda
To errhellipis expensive
Medication errors cause temporary harm
Disability and death
The human costs are incalculable
The financial cost is estimated and very likely underestimated
bull ge $171 billion every year
bull Range found in literature
Most common reason for malpractice lawsuits
bull Average amount awarded by the courts is $31 million
HHS 2010
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Institute of Medicine
Some Background
1998 The Quality of Healthcare in America project
‒ Develop a strategy that will improve quality
‒ Review and synthesize literature
‒ Develop communication strategies
‒ Articulate framework of incentivesfoster accountability
‒ Identify factors that improve quality of care
‒ Develop research agenda
To errhellipis expensive
Medication errors cause temporary harm
Disability and death
The human costs are incalculable
The financial cost is estimated and very likely underestimated
bull ge $171 billion every year
bull Range found in literature
Most common reason for malpractice lawsuits
bull Average amount awarded by the courts is $31 million
HHS 2010
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
To errhellipis expensive
Medication errors cause temporary harm
Disability and death
The human costs are incalculable
The financial cost is estimated and very likely underestimated
bull ge $171 billion every year
bull Range found in literature
Most common reason for malpractice lawsuits
bull Average amount awarded by the courts is $31 million
HHS 2010
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Bringing it back to basicshellip
-Right Patient
-Right Route
-Right Dose
-Right Time
-Right Medication
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Medical Errors vs Adverse Events
Medical Error- ldquo The failure to complete a planned action as intended or the use of a wrong plan to achieve an aimrdquo (IOM)
Adverse Event- ldquo An injury caused by medical management rather than by the underlying disease or condition of the patientrdquo
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Medication Use Process
Any interruptions along the way of this path can cause errors and lead to adverse outcomes
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Reconciliation
Systematic validation and verification of medical history and orders
It involves comparing a patientrsquos current drug prescription with all medications currently taken
It should be undertaken at every transition of care
Top causes of reconciliation errors include
bull Performance deficit
bull Transcription documentation
bull Communication interruption
bull Work flow interruption
Avoid omissions
Duplications
Dose errors
Drug interactions
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Med Reconciliation
There are 5 main steps
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
One Study Reported medication errors by unit
Labor amp Delivery 2218 484
Maternity Unit 2143 468
OB PACURecovery 222 48
Total 4583 100
Obstetrical Area n Percent
Kfuri et al (2008) Data from 112003 ndash 12312005
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Examplefrom PA
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
System factors that influence errors
Staffing Levels ndash high nursept ratio rushing no breaks
RN skill mix ndash heavy burden
Shift length ndash 12h (3Xrsquos ) vs 8h also time of dayweek
Patient acuity ndash higher stress on RN
Organizational climate
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Other factors contributing to med errors by nurses
Long work hours ndash shifts
Fatigue
Inefficient care process
Workplace design
Workload of documentation
Lack of knowledge of
medication
Sources Institute of
Medicine and Hewitt
Mathematical
errors
Environmental
stressors
Communication
problems
Not following the 5
Rights
Look alike Sound
alike medications
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Swiss Cheese Model- med errors
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Nurse leaders want to knowWhy are nurses not following the 5 rights
Do nurses lose interest over time
Is it because they are no longer being observed
Are they overburdened with heavy workloads
Are they emotionally affected
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
bull Incompetent ndash they arenrsquot qualified
bull Guilty ndash they were careless
bull Scared ndash something punitive will happen
bull Worried ndash harm will result for the patient
bull Afraid ndash co workers disrespect reactions
bull Distracted-interrupted during the process
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Professional Nurse rdquoknowledge workersrdquo
Described as people who think for a living
Valued by society for their
bull education knowledge
bull expertise in a specific subjectarea
Must have high quality cognitive processing ability
Patients Family may interpret as
bull Not focusing on them
bull We appear as thought we are distracted
bull Not caring ndash Not listening
Our brain is busy ldquojugglingrdquo
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Cognitive Neuroscience ResearchFactors that can influence errors
Interruptions - q 11 minutes 25 minutes to resume
Distractions
bull Internal
bull mind wandering
‒ Requires complex mental activity to control
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
External
‒Requires anticipatory planning ndash ie vests zones
bull Inhibiting distractions early before they gain momentum is difficult and cannot easily be controlled
Multitasking
Lack of focus
Task switching
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Cognitive Neuroscience Research How does the brain deal with multitasking
The human brain
bull can make only 1 decision at a time
Back and forth when trying to simultaneously process
bull Loss of accuracy
bull Takes more time switching back and forth
Maximum of items people can consciously hold is 4
The ability to switch is diminished with age
Clark A et al (2012) Clinical Nurse Specialists
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
StrategiesReduce errors during administration
Avoid engaging in nonessential communication
Medication administration checklist
Teamwork having other staff cover telephone calls and
interruptions
bull Special garment (vest or sash)
bull No Interruption Zone
bull Scripting for when nurses are interrupted
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Older Nurses
Older adults fared differently when compared to young adults
N = 40 20 ~age 245 Y=20 with ~ 20 ~age 69
Older ndashbull more difficulty letting go of distractionbull Slower to regain focus on 1st task
Aging does appear to cause loss of multitasking function
Itrsquos more difficult to switch tasks easily
Older nurses often likely to be pulled
Respectful approach
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Error Analysis-influential factors
Maintain Safety
Manage the environment
bull Distractions ndash phone calls family questions pulled away
bull 293 - interrupted by other nurses
bull 228 - system failure (missing medication)
3 level of errors have been identified
1Skill based (slips and lapses)
2Rule based (poor choices or inappropriate rules)
3Knowledge-based (apply thinking to new situation)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Reporting Medication Errors
Medication errors are under reported
bull Itrsquos estimated only 1 out of every 5 dose errors are reported
Brady A et al (2009)
bull Confusion regarding definition of a medication error
Gladstone 1995 Mayo et al 2004 Ulanimo et al 2007
bull Nurses did not believe ldquoright time was as crucial as other five rights
bull Timing is part of nursing judgment
bull Stetina et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Uncertainty if the medication error must be reported
Fear of disciplinary action if medication error is reported
Therefore evaluation to identifying root causes of medication errors is obscured by these factors
Gladstone J (1995)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Questions
What is the process for administering medications at your
institution
How has this process changed since you entered
nursing
What do you consider a medication error
What procedures exists to decrease medication errors on
your unit
What is the role of pharmacytechnology in preventing
med errors
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
What is the process for reporting medication errors at
your institution
If you have made a medication error and are willing
please respond to the following
bull Give an example of a time you found a med error
and reported it
bull Give an example of a time you found a med error and
did not report it
How would you change the process of reporting med
errors today
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
High Alert Medications used in OB
Andrenergic agonistsbull Epinephrine
Andrenergic antagonistsbull Labetalol
Anticoagulantsbull Heparin Warfarin
DextroseEpidural medications Insulin Oral HypoglycemicsNarcoticsSpecifics
bull Magnesiumbull Oxytocinbull Promethazine
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
2008 Consensus
Report
Standards forPerinatal Care
The safe practices are defined as
processes that shouldbe universally used in healthcare settings to
reduce the risk of harm resulting frombull processesbull systemsbull environments of
care
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Update from NQFrsquos 2012 Perinatal and Reproductive Health Measures
bullNQF is a private nonprofit organization that develops and
implements a national strategy for healthcare quality
measurement and reporting
bullNQF analyzed the available scientific evidence to define a
set of practices
targeted at improving patient safety
bullEndorsed 14 of 21 measures to increase perinatal safety
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Case Presentation
bull 29 yo 30+2 arrives from ED 430 pm Friday
bull G3 P0 BMI = 40
bull Vaginal bleeding (~500mL gush)
bull Hx 2001 dx CHTN 2008 Artificial Heart Valve
bull Hx 2009 Left side CVA (Stroke)
bull Hospitalized twice for CHF 2010 2011
bull Anticoagulated with Warfarin ndash target INR 25
bull Medications 3 anti-HTN agents to control BP
bull Bedside US reveals ~ 350-500mL clot (abruption)
ndash T = 980
ndash HR = 92
ndash BP = 13292
ndash R = 20
Questions
bull Risk factors
bull Assessment
bull SBAR
VS
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Cardiovascular Risk
bull Embolic Stroke
bull Clot forms in the heart
bull Travels to the brain
bull Hemorrhagic Stroke
bull Blood vessel ruptures
bull Damages the brain
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Heparin
2007 Dennis Quaidrsquos twins were given 1000-fold overdose because heparin was mis-stocked in the Automated Dispensing Cabinets (ADC) Pyxis
At that time the packaging for heparin and heparin lock flush were very similar
Bar code scan was developed to correct the process error
Chasing Zero
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Bar Code Medication Administration
BCMA brings trade-offs
bull Human automation
bull Lean Approach
bull Procedure violation
‒ When Hard Stops fail
bull Work arounds
bull Work flow
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Medication Safety InitiativesThe Big Three
1 Computerized provider order entry (CPOE)
2 Bar code medication administration (BCMA)
3 Smart IV Pumps
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Unfractionated Heparin
for PE
bull Loading dose 150 unitskg bolus
bull 15-25 unitskghr
bull Transition to SQ or low molecular weight heparin
Side effects
bull Hemorrhage hypotension
‒ Protamine sulfate 1mg neutralizes 100 units of heparin
Should not exceed 50 mg
Initial treatment in single dose
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Follow aPTT 4 hours after initiation and after dose
changes
Goal with heparin therapy aPTT 15 -25 x control (60-80
seconds)
Monitor coagulation lab trends
Risk of epidural or spinal hematoma
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Magnesium Sulfatebull Mechanism
ndash Calcium antagonistInhibits voltage independent calcium channels at the myometrial cell surface
bull Efficacy ndash Not confirmed ndash Cochrane review
bull Rationalendash Safe and familiar neuroprotective
bull Safety and side effectsndash Flushing nausea blurred vision
headache pulmonary edema cardiac arrest - caution if creat gt10
ACOG Practice Bulletin 43 2003Iams J Obstetrics Normal and Problem Pregnancies 4th d 2002 Preterm birth Williams Obstetrics 22nd ed 2005
1 Tocolytic used in the US
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
ManagementbullMagnesium sulfate given for seizure prophylaxisbull 4 - 6 g loading doserarr 1-2 g per hour maintenance dose
Magpie trial established 1 gmhr dose effective
Controversy over whether MgSO4 is needed in
mild preeclampsia when closely monitored
bull Treatment usually continues for 24 hours after birth
bull Most common preventable errors in preeclampsia mgmt
leading to maternal death involved inattention to BP control
and SS of pulmonary edema
Clark S Maternal death in the 21st Century Am J Obstet Gynecol 2008
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Development of the California Toolkit lsquoImproving Health Care Response to Preeclampsiarsquo was funded by the
California Department of Public Health (CDPH) Center for Family Health Maternal Child and Adolescent
Health (MCAH) Division using federal Title V MCH funds
CMQCC Preeclampsia Toolkit
Preeclampsia Task Force MembersMaurice Druzin MD ndash StanfordElliott Main MD ndash CMQCC
Barbara Murphy RN ndash CMQCC
Tom Archer MD ndash UCSD
Ocean Berg RN CNS ndash SF General Hospital
Brenda Chagolla RNC CNS ndash UC Davis
Holly Champagne RNC CNS ndash Kaiser
Meredith Drews ndash Preeclampsia Foundation
Racine Edwards-Silva MD ndash UCLA Olive View
Kristi Gabel RNC CNS ndash RPPC Sacramento
Thomas Kelly MD ndash UCSD
Claire Brindis DrPH UCSF
Dana Hughes DrPH UCSF
Larry Shields MD ndash Dignity HealthNancy Peterson RNC PNNP ndash CMQCC
Christine Morton PhD ndash CMQCC
Sarah Kilpatrick MD ndash Cedars Sinai
Richard Lee MD ndash Univ of Southern California
Audrey Lyndon PhD RNC ndash UC San Francisco
Mark Meyer MD ndash Kaiser SD
Valerie Cape ndash CMQCC
Eleni Tsigas ndash Preeclampsia Foundation
Linda Walsh PhD CNM ndash UC San Francisco
Mark Zakowski MD ndash Cedars Sinai
Alana Moore
Michael Orosco MD Kaiser San Diego
4
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Magnesium for Eclampsia
4 ndash 6 grams bolus over 15 -20 min per institution PampP bull ACOG CMQCC
For eclampsia ndash use smart pump (Alaris) library
2 RN check
RN remains at bedside for duration of bolus (staffing)
bull Antidote Give 10 Calcium Gluconate 10ml (1 gram) slow IV push over 3 minutes
‒Calcium Gluconate override from Pyxis
may repeat every hour if needed up to eight doses24 hours
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Severe Preeclampsia
Each institution should prepare its own medication toolbox specific to its protocols
bull Labetalol 20 mg IV bolus rarr 40mg rarr 80mg (max 300mg)
bull Hydralazine 5- 10mg doses every 15-20 minutes
bull Nifedipine 10 mg PO repeat every 30 minutes
bull Labetalol 200mg PO repeat every 30 minutes
bull Esmolol 1-2 mgkg IV over 1 minute
bull Propofol 30-40 mg IV bolus
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Magnesium Sulfate - Root CausesConditions that make accidents more likely
Different protocols policies procedures from one unit to another
Multiple pump settings
Inadequate labeling of IV fluids
Not removing the Magnesium from the IV port when it is has been discontinued
Thinking women on Magnesium are ldquostablerdquo
Assumptions and miscommunication between nurses andor physicians
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
ACOG Executive Summary on Hypertension In Pregnancy Nov 2013
1to diagnose preeclampsia with new onset hypertension
3 The total amount of proteinuria gt 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia
4 Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic
The term ldquomildrdquo preeclampsia is discouraged for clinical classification The recommended terminology is
a ldquopreeclampsia without severe featuresrdquo (mild)b ldquopreeclampsia with severe featuresrdquo (severe)
2 Proteinuria is not a requirement 18
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
5 Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)
6 Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications
7 Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension
19
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
ACOG Executive Summary on Hypertension
In Pregnancy Nov 2013
8 The postpartum period is potentially dangerous Patient education for early detection during and after pregnancy is important
9 Long-term health effects of magnesium should be discussed
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
CMQCC Preeclampsia ToolkitKey Clinical Pearls
Use of preeclampsia-specific checklists team training and communication strategies and continuous process improvement strategies will likely reduce hypertensive related morbidity
Use of patient education strategies targeted to the educational level of the patients is essential for increasing patient awareness of signs and symptoms of preeclampsia
71
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Example Case
A 27 yo was admitted to LampD with cramping abdominal pain vaginal bleeding and leaking of clear fluid at 27 wks
In an attempt to stop preterm labor the OB prescribed IV magnesium sulfate with a 6 g bolus dose over 30 min followed by a continuous infusion of 2ghr
A 20g500ml bag of magnesium was used and the smart pump was programmed to deliver a continuous infusion at 12 ghr
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
The rest of the story
The pt became flushed short of breath she called for a nurse
The pt was found felling dizzy and hypotensive and quickly proceeded to become unresponsive
CPR was initiated magnesium infusion stopped and she was given a dose of Ca Gluconate
The pt responded to emergency treatment - the baby was delivered by CS a few days later dt unrelated preterm complications
Both mom and baby were discharged wo harm
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Common Factors in MgSO4 Deaths
Use of 1000ml IV bags w40 g of MgSO4
Temporary removal of the IV line from the IV pump
A busy unit andor understaffing
Transfer to a lower level of care
Unwitnessed respiratory arrest
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Monitoring Recommendations
Frequently assess VS O2 sat DTRrsquos and level of consciousness FHR and uterine activity
Assess for signs of toxicity (visual changes somnolence flushing muscle paralysis loss of patellar reflexes) or pulmonary edema and notify the MD if observed
Subsequent assessment
bull Every 15 min for the 1st hour
bull 30 min for the 2nd hour
bull Hourly
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Beta-MimeticTerbutaline
bull Mechanismndash Beta-2 stimulation rarr uarr cyclic AMP darr Calcium
bull Efficacyndash May delay delivery by 2 to 7 days
bull Rationalendash Effective short-term arrest of contractions
bull Safety and side effects ndash significant and frequentndash Maternal tachycardia pulmonary edema glucose intolerance ndash
should only be given as inpatient
ndash Not used as a 1st line or with OB patients with cardiac dz
ndash Dose ndash Terbutaline 025 mg subcutaneously only every 2 hr x 2
ACOG Practice Bulletin 43 2005 Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
2011 FDA issues warning
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Top 10 reported medications errors in OB
1 Ampicillin
2 Oxytocin
3 Ibuprofen
4 Cefazolin
5 Oxycodone
6 Ketoralac
7 Magnesium sulfate
8 Terbutaline
9 Gentamycin
10MeperidineCiarkowskiS et al (2010)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Most common OB medsAssociated with Patient Harm
Oxytocin
Magnesium Sulfate
Terbutaline
Terbutaline
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Medical-legal Claims
219 of claims involving neurologically impaired babies
147 of claims involving stillbirth or neonatal death
included management of oxytocin
~ 12 of all paid claims involve allegation of oxytocin misuse
Clark Belfort amp Dildy (2006)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Induction of Labor Number 107 August 2009Replaces Practice bulletin 10 Committee Opinion Numbers 228 248 283
Classify indication and contraindications
Describes the various agentsmethods used for IOL
Summarize effective agents based on outcome data
Outline the requirements for safe clinical use
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
ACOG Recommendations
Use National Institute of Child Health and Human
Development (NICHD) terminology throughout the protocol
Clearly explain the purpose of the protocol
Describe pre-induction assessment of the patient
bull strongly recommend incorporating pre-induction
checklist
State any pre-induction documentation requirements
List the contraindications to labor induction
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Describe the intrapartum physician andor nursing
assessment and documentation that may be required
bull strongly recommend utilizing a checklist as part of the
ongoing assessment
List the parameters for discontinuation of the induction
agent
Describe in detail interventions to be used if tachysystole
FHR abnormalities or other complications occur
Outline the notification process of providers should the
induction agents be discontinued or when nursing
interventions do not readily resolve tachysystole fetal
heart rate abnormalities or other complications
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Oxytocin Checklist
The use of a checklist is highly recommended when administering oxytocin
Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation
The Hospital Corporation of America (HCA) and the Institute of Healthcare Improvement (IHI) have developed oxytocin checklists that could be incorporated into your institutionrsquos Pitocin protocol
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
ldquoIn userdquo oxytocin checklistHCA Perinatal Safety Initiative
Recommended Oxytocin ldquoIn Userdquo Checklist for Women with Term
Singleton- Babies
ldquoThis Oxytocin ldquoIn Userdquo Checklist represents a guideline for care
however individualized medical care is directed by the physicianrdquo
Checklist will be completed every 30 minutes Oxytocin should be
stopped or decreased if the following checklist cannot be
completed
Date and time completed _____________
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Oxytocin checklist
Fetal Assessment indicatesAt least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or
adequate variability
for 10 of the previous 30 minutes
No more than 1 late deceleration occurred
No more than 2 Variable decelerations exceeding 60 seconds in duration and
decreasing greater than 60 bpm from the baseline within the previous 30 minutes
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Oxytocin checklist Uterine Contractions
No more than 5 uterine contractions in 10 minutes for any
20 minute interval
No two contractions greater than 120 seconds duration
Uterus palpates soft between contractions
If IUPC is in place MVU must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg
If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated
MVU = Montevideo Units
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Results Checklist based protocol
Significant decrease in max rates of oxytocin without lengthening labor or increasing operative interventions
Newborn outcomes improved
CS rate dropped from 236 to 21 in 1 year
A 50 decrease in adverse outcome claims
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Oxytocin (Pitocin) Induction andAugmentation of Labor
Policy and Procedure BC20BIRTH CENTER ndash Pt Care
8 PagesHISTORY OF THE POLICY
bull Issue Date January 2001VIII APPENDIX
bull Appendix A Bishop Scoring Systembull Appendix B Chart of Oxytocin doses in mlhrbull Appendix C Montevideo Units
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Staffing
11 Nursing
ldquoIf an RN is not available to clinically evaluate the effects of the oxytocin infusion at least every 15 min the infusion should be discontinued until that level of care is availablerdquo
(AAP amp ACOG 2002 and AWHONN 2002 2010)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Staffing the Nurse Patient Ratio
12 during inductionaugmentation with oxytocin
(AAP and ACOG Guidelines for Perinatal Care 2007)
11 with high risk and active management
bull severe preeclampsia during the active phase of the first
stage of labor
bull second stage of labor A nurse must be able to clinically
evaluate the effects of oxytocin at least every 15minutes
(AAP amp ACOG 2007)
The oxytocin infusion should be discontinued if this level of
nursing care cannot be provided A LIP who has privileges
to perform a cesarean birth should be readily available
(AAP amp ACOG 2007)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Opioids and Patient Controlled
Anesthesia (PCA)1 Prescribing safety
a) Clear pain assessmentb) Standardized order set
2 Dispensing safetya) Prefilled labeled syringesb) Standardized concentration
3 Administration safetya) Standardized infusion pumps (consider bar-coded
technology)b) Education of patient regarding safe use of PCAc) No button use by proxy ndash only the patient uses the
PCA buttond) Independent double checks when changing
syringes or changing infusion rates4 Monitoring safety
a) Continuous pulse-oximetryb) Standardized monitoring parametersc) Use sedation scores
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No 286 October 2003)
Efforts to reduce the occurrence of these errors should be ongoing
Computerized physician order entry systems can be effective in reducing prescribing errors they are costly and may not collect data that support quality improvement activities
In the absence of computerized physician order entry systems the following steps should be adopted to reduce errors in prescribing and administering medications
Improve legibility of handwriting
Avoid use of nonstandard abbreviations
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
ACOG COMMITTEE OPINIONNumber 447 bull December 2009 (Replaces No
286 October 2003)Check for drug allergies and sensitivities
Always use a leading 0 for doses of less than 1 unit (eg 01 mg not 1 mg) and never use a trailing 0 after a decimal (eg 1 mg not 10 mg) ldquoalways lead never followrdquo
All verbal orders should be written down by the individual receiving the order and read back
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Strategies used by Critical Care Nurses to Identify Interrupt and Correct Medical ErrorsHenneman E A et al (2010)
To describe error recovery strategies used by critical care nurses
Collected data from audio taped focus groups
bull 20 nurses from 5 CCUrsquos at 4 medical centers
17 strategies were identified
bull 8 Identify
bull 3 Interrupt
bull 7 Correct
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Strategies Continued Nurses use strategies to Identify ErrorsHenneman E A et al (2010)
1 Knowing the patient ndash history plan report family
2 Knowing the ldquoplayersrdquo - MD previous RN
3 Knowing the plan of care ndash shift report rounds
omissions
4 Surveillance ndash organize room check drips
5 Knowing policyprocedure ndash aware of monitoring
6 Double-checking ndash ldquothey want me to do thisrdquo
7 Using systematic processes ndash checklists report
forms
8 Questioning ndash ldquoWould you review the orders with
merdquo
Novice or Physician
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses used 3 strategies to interrupt errors
1 offering assistance - help instead of confront
(saving face)
2 clarifying - donrsquot say ldquonordquo say ldquowhyrdquo
3 verbally interrupting - hold on ndash donrsquot do anything
- stop
The nurses ability to interrupt was influenced by
bull experience and confidence
bull support of other nurses opinion poll
bull fear perceived intimidation
bull prior experience regret
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Strategies Continued IDENTIFY ERRORS
Henneman E A et al (2010)
Nurses used 6 strategies to correct errors
1 Persevering ndash unrelenting attention phone calls pages
2 Being physically present ndash face to face
3 Reviewing or confirming the plan of care ndash Ask ldquowhyrdquo
4 Offering options ndash Can we give a one time dose Ask ldquoifrdquo
5 Referencing standards or experts ndash reference expert
research article
6 Involving another nurse or physician ndash Chain of command
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Strategies Continued IDENTIFY ERRORSHenneman E A et al (2010)
Nurses reported feeling
bull Frustrated
bull Challenged
bull Compelled
bull Push harder chase them down get in their face
Avoided some formal leaders
bull Nurses or MDrsquos that were overly critical or intimidating
Conclusion
bull Nursing vigilance can prevent potentially dangerous
situation from reach or harming the patient
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
When a medication error occurshellip
Full disclosure of errors to patients and families
bull Institute policy
bull Must be timely
bull Must be complete
bull Institute support for those involved
bull Positive outcomes
Institute for Safe Medication Practice (2010)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Interventions Committee ndash Error Review
Fair and Just Culture required
All ldquoerrorsrdquo tracked and catalogued regardless of whether they reach the patient or cause harm
Errors viewed as systems failures with examination of policies EHR functionality workflow issues etc
Recommendations made for templates policies workflow and EHR functionality
Mechanism for dealing with individuals with performance issues
Institute for Safe Medication Practice (2010)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
The Principles of the ProgramBehavioral Skills (CRM)
bullKnow your environment
bullAnticipate and plan
bullAssume the leadership role
bullCommunicate effectively
bullDistribute work load optimally
Allocate attention Wisely
Utilize all available
information
Utilize all available
resources
Call for help early
enough
Maintain professional
behavior
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Know Your Environment
Sounds simple but itrsquos not
Emergency medications or equipment that is rarely used ndashwhere found
bull Triage rarr ORrarr
‒arm boards smart pump pressure bags rapid infuser
Equipment and supplies move
Staff vacations relief float staff
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Instrument amp Supply RoomAccess to Emergency Supplies
Rearranged supplies and labeled bins
Stocked Emergency supplies in red bins amp moved to upper shelves
Re-labeled frequent use bins with known names
Grouped related itemss
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
OB Hemorrhage Cart 2014
Quick access to emergency supplies
Refrigerator for meds
Establish necessary items and par levels
Label drawerscompartments
Include checklists
Develop process for checking and restocking
Educate nursing and physician staff
McNulty 2014
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
87
Draft 12
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safetyShields L et al (2014) AJOG
Checklist for protocol and data compliance
Risk assess
Correct blood bank request
Quantified blood loss
Correct lab results were obtained
gt 2 Uterotonics give wo MD present
Blood given per protocol
Safehealthcareforeverywomanorg
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large national health care system Clark S et al (2012) AJOG
Systematic approach to identify near-miss events on LampD
bull Medication errors were the highest reported
‒ Temporary verses permanent harm
bull MD response and decision making rarr Greatest potential
of harm
bull Barriers in place to reduce harm
‒ Weaknesses (Holes)
‒ Holes align
bull Institutions react to harmful event rarrInterruption of work
flow
‒ Reactive
bull IOM suggests voluntary reporting of near-miss
‒ Proactive
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Intimidating and Disruptive Behaviors
Foster medical errors
Contributes to poor patient satisfaction
Contributes to preventable adverse outcomes
Increases the cost of care
Causes qualified clinicians administrators and managers to seek new positions in more professional environments
JACHO Sentinel Event Alert 40 708
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Letrsquos make a Difference
bull Medical errors should not be criminalized
bull Fear is a major barrier to action
bull Our actions need to focus on patient safety
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Promote a Culture of Safety
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Promote a Culture of Safety
The people who cared for their Mom are so sorry and wersquore trying to
learn from our mistakes Wersquore working hard with all individuals at all
levels to identify safety threats and together wersquoll find answers and get
better at speaking up for patients like their Mom
We promise to do our best to create hospitals that are safe places to
work free of fear and retribution
And because of the courage of their Dad and his work nurses and
doctors are better able to protect patients like their Mom and we have
learned from this terrible mistake and it wonrsquot happen again
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Was ldquoJust A Routine Operationrdquo
Martin Bromiley lost his wife in 2007
He identifies lsquowe are all wrong no matter how good we arersquo
We need people around us to tell us
Be open to suggestions Listen to your team Step up and lead Clear
communication is key
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Summary
Medication delivery is a complex multidisciplinary process
The root causes of medications errors are multifactorial
Nurses should clearly understand what constitutes a medication error
A safe non-punitive work environment is essential for errors to be accurately reported and evaluated and to bring about change
Health care providers need to work together to review errors and implement strategies that promote reliable safe systems
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Happy Nursesrsquo Week
zdoggmdcomehr-state-of-mind
httpzdoggmdcomyoure-welcome
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Nurses are being increasingly
recognized for their role in
reducing medical errors
Happy Nursesrsquo Week
Thank YouThank you also to Valerie Huwe for her mentorship
Meghanduckucsfedu
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
References
ACOG (2009) Obstetrics amp Gynecology Volume 114 - Issue 6 - ppg 1424-1427 Committee Opinion No 447 Patient Safety in Obstetrics and Gynecology doi 101097AOG0b013e3181c6f90e
ACOG Practice Bulletin 43 (2005) Normal and Problem Pregnancies 4th ed 2002 Preterm birth Williams Obstetrics 22nd ed
bull CiarkowskiS et al (2010)
Clark A et al (2012) Clinical Nurse Specialists
Clark S (2008) Maternal death in the 21st Century Am J Obstet Gynecol
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)
Clark Belfort amp Dildy (2006)
Flanders amp Clark Clinical nurse specialist (2010) vol 24 (6)
Henneman E A et al (2010)
Kacmar RM Mhyre JM (2015) Obstetric Anesthesia Patient Safety Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery Anesthesia Patient Safety Foundation
McNulty 2014
Philadelphia Patient Safety Advisory (2009) Dec 166 (Suppl 1)1-6
Shields L et al (2014) AJOG
Stetina P et al (2005)