Raising the Bar On Infusion Safety: Patient Safety Programs

at Western Maryland Health System and Cameron Memorial Community Hospital

Improving Infusion Pump Safety:

Achieving Excellent Compliance With the Drug Library

August 8, 2016

AAMI Foundation Vision: To drive the safe adoption and safe use of

healthcare technology • National Coalition for Infusion Therapy Safety • National Coalition to Promote Continuous Monitoring of

Patients on Opioids • Compendium: Opioid Safety & Patient Monitoring

• National Coalition for Alarm Management Safety • Compendium: AAMI Foundation Management of Clinical

Alarm www.aami.org/thefoundation

Please Consider Making a Donation! http://my.aami.org/store/donation.aspx

A Special Thanks

Thank You to Our Premiere Industry Partners

Without the generous support of our industry partners, we would not be able to produce the many

tools and deliverables created by the coalition to help you improve infusion therapy safety. The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial

content.

Platinum Diamond Gold

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Nursing Continuing Education Disclosure Statement This seminar is jointly provided today with our co-provider, the National Association of Clinical Nurse Specialists (NACNS).

1.0 contact hour will be awarded for this seminar. This seminar may be accessed online at the AAMI Foundation website for nursing CE up to two years from today’s date.

http://my.aami.org/store/detail.aspx?id=PSSINFSFTY1608

This continuing nursing education activity was approved by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation (ANCC).

Criteria for successful completion includes attendance at the session and submission of a completed evaluation form. You can submit the fee for the CE credit by going to the AAMI store at (link will be sent in follow-up email). A link to the evaluation form will be sent to you for completion and a certificate sent to you upon completion of the evaluation.

The planning committee members have declared no conflict of interest along with our faculty for today’s session.

Contributions to the AAMI Foundation have been received from the identified sponsors to support program initiatives and projects. However, the program content for today’s seminar has been planned independently by AAMI staff with the seminar presenters.

Approval of the continuing education activity does not imply endorsement by the provider, ANCC or the Alabama State Nurses Association.

Polling Questions

Speaker Introductions

• Christine Ruhl, BSN, MBA, CCRN Director, Critical Care Services Western Maryland Health System

Infusion Safety: Why?

• Uphold our Culture of Safety • Improve Patient Safety • Improve Medication Administration

Processes and Monitoring

Opportunities

• Old Technology

• Wide Variety of Technology, Supplies, and Practices

• Limited Safeguards • Relied on manual programming for accuracy • Relied on direct observation/self reporting for medication errors • Under recognized and under reported • No ability for retrospective review

• In 2011, removed all old technology and implemented over 400 BBraun Outlook ES smart pumps throughout our health system. 9/25/2013 10

Drug Libraries • Drug libraries were developed as a collaborative effort between

pharmacy, providers and bedside clinicians

• Variability in concentrations/dosing was standardized based on Evidenced Based Practice

• Utilized clinical advisories, adding double checks to high risk meds including insulin and heparin

• Soft max and hard max limits alert clinicians, help to prevent errors

• Clinicians with a variety of critical care experience including floating staff are able to effectively titrate infusions in a safe environment

Achieving 100% Compliance

• Established targets of 95% across key infusion metrics • Dose delivered infusions • Rate delivered infusions • Correct location • Correct care area

• Initial compliance 49-93% six weeks post implementation

Educational Opportunities • Found in practice staff increasing rate to bolus patient rather than using

the bolus feature

• Communication to staff regarding outcomes, “good catches” and averted errors provides “real-life” examples and promotes staff buy-in.

• Insulin entered as the bag volume 100 rather than the rate of 10 units/hour

• Newsletter talked about life threatening events related to smart pumps and preventable infusion errors.

Real Time Audits • Implemented weekly audits • Provide direct observation to document compliance

and identify barriers

Outlook ES DoseGuard and RateGuard Drug Library Compliance Audit

Unit: _______________________ Census: ________ Date: ______________ Auditor: _______________________

Room/ Bed :

Total #

Pumps

DoseGuard Appropriate

Y/N or N/A

RateGuard Appropriate Y/N or N/A

Correct Location

Y/N

Correct Care Area Y/N

Patient ID

Y/N Nurse's Name

Comments: (Include drug names for inappropriate use of drug library)

Compliance Rates

Target 12-2011 7-2012

Dose Delivered 95% 93% 100%

Rate Delivered 95% 49% 100%

Correct Location 95% 92% 100%

Correct Care Area

95% 62% 100%

Compliance Monitoring

Ongoing Performance Improvement

• Are we always 100%???

• Audits continue monthly on all in-patient units.

• On the spot feedback and education

• Ongoing data reports to staff, pharmacy and nursing management, proactive mixing of infusions

• Accountability

Retrospective review of DoseGuard & RateGuard alerts, increasing awareness of practice issues, learning opportunities

Performance Improvement

Analytics

Alert Detail Report – Programming Sequence

The Data 2015 Goal YTD

DoseGuard 95% 92%

RateGuard 95% 92%

Correct Location 95% 94%

Correct Care Area 95% 86%

9/25/2013 21

2016 Goal YTD

DoseGuard 95% 100%

RateGuard 95% 98%

Correct Location 95% 97%

Correct Care Area 95% 92%

Lessons Learned

• Alert fatigue from soft maximum limits set too low vs. actual infusion practices was a concern

• Limits adjusted to prevent potential alert fatigue and maintain safe dosing • Integrating with Nurse Call system

• Ongoing Education • New staff, bolusing, new drugs, oncology drug infusions

• Ongoing Communication with Staff • Outcomes, good catches, averted errors

• Requires Continual Focus—Hard Lesson to Learn!

Key Advice • Champions and Leadership support are keys to success!

• Have to have an engaged multidisciplinary team ranging from the bedside clinician to senior executive management

• Research! Know your challenges, safety issues, and goals, so your infusion safety program is successful.

• Involve clinical staff (providers, nursing and pharmacy) in decision making for drug libraries and standardization.

• Be realistic and understand infusion safety is an ongoing process!!

The Future

• Continue to Maintain Focus on Infusion Safety • Monitor Evidenced Based Medicine • Integrate with EHR

Speaker Introductions

Andy Aldred, PharmD, MBA Director of Pharmacy and Materials

Management Cameron Memorial Community Hospital

Angola, IN

• Improvement Identification • Goal Development • Action Plan • Results • Sustainability • Additional Improvements • Current Improvement Efforts

Agenda

Improvement Identification

REMEDi Central

Goal Development

Need to Improve I.K.P. data

• Developed in Med Safety Committee

• Current state from vendor • Benchmark from REMEDi

Central • Goal

• Improve SMART IV pump library compliance rates to 90% or above

Improve Library settings • Quarterly vendor report • Vendor software (e.g. CQI Reporter) • REMEDi Central (IPI)

Action Plan

Alerts Profile

REMEDi Central

Top 5 Medications Causing Alerts

REMEDi Central

Med Specific Drill Down

REMEDi Central

Drug Limit Library Explorer

REMEDi Central

• Vendor onsite to retrain staff • Compliance Rounds

• Used spreadsheet-tool • Lean Daily Management

Action Plan

• Staff Feedback Mechanism

Action Plan

Help you

Help me

• Policy Changes • Blood

• Oxytocin

• KVO

Action Plan

Action Plan • Pharmacy staff focus

• Library settings • Pump usage

Results

Results

REMEDi Central

• Ever vigilant

Sustainability

MONTHLY DASH TARGET

RANGES:

CategoryPerformance Indicator Min Opt. Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep TOT

Alaris Total Alarms 2379 3038 2977 3134 2694 3516 3279 3592 2661 2881 3404 3537 3091Guardrails alerts 50 40 18 48 33 36 34 51 37 38 43 30 73 32 39.42

Cancelled infusions 10 8 5 16 4 5 10 15 9 7 14 4 6 10 8.75 Reprogrammed infusions 15 5 8 15 12 8 8 17 17 5 5 6 7 3 9.25 Overrides 25 15 5 17 17 23 16 19 11 26 24 20 60 19 21 Guardrails suite usage (%) 92.0% 97.0% 82.6% 97% 98% 96% 97% 94% 96% 97% 96% 97% 97% 97% 95.3%

Fiscal Year: 2015

QTR 4QTR 3QTR 2QTR 1

Organizational Awareness

Signage

Additional Improvement • Reduce unnecessary alerts

REMEDi Central

Alerts per Month per Device

Range of 2.5-4.4/month

REMEDi Central

Improvement

Reduced range to 0.9-2.5/month

REMEDi Central

Overrides to Reprograms

ORGANIZATIONAL CULTURE DRIVES OPERATIONAL PERFORMANCE: A COLLABORATIVE STUDY

2016

Benjamin B. Dunford Andrew Aldred Matthew B. Perrigino Scott Hirschy

What We Did… Diagnosis

• Qualitative interviews of 100+ personnel • Engagement survey

Intervention • 360○ feedback for top management team • Teambuilding and conflict resolution • Strategic planning led by CEO and task force

Follow up

• Performance management interviews • Web-based reporting

What We Found… Workarounds are between 11% and 21% lower in teams with more positive climates:

Future directions… Expand to other hospitals with customizable research designs & potential for benchmarking

Future/Ongoing Initiatives

9/25/2013 48

Thank you for attending!

If you are interested in obtaining a 1.0 CE credit after you watch this Patient Safety Seminar, you may purchase the credit at the AAMI Store for $25.00 at this link: http://my.aami.org/store/detail.aspx?id=PSSINFSFTY1608

Mark Your Calendars! August 26, 2016; 12pm to 1pm

Continuous Monitoring of Patients on Opioids: Initiatives at Methodist

Specialty and Transplant Hospital and Community Health Network Speakers: Theresa Kloewer, MSN, RN VP of Nursing Methodist Specialty and Transplant Hospital San Antonio, TX Julie Painter, MSN, RN, ONC Clinical Nurse Specialist Community Health Network Indianapolis, IN Register: https://attendee.gotowebinar.com/register/1892516072116332289

CE credit of 1 hour has been approved for this seminar

Complimentary Resources Safety Innovations Series Alarms Management Patient

Safety Seminars • Seminar Recordings • Webinar Slides • Key Points Checklists

Opioid Safety & Patient Monitoring Compendium AAMI Foundation Alarm Compendium

Thank You to Our Premiere Industry Partners

Without the generous support of our industry partners, we would not be able to produce the many

tools and deliverables created by the coalition to help you improve infusion therapy safety. The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial

content.

Platinum Diamond Gold

Questions?

• Post a question on AAMI Foundation’s LinkedIn

• Type your question in the “Question” box on your webinar dashboard

• Or you can email your question

to: mflack@aami.org.

Consider Making a Donation to the AAMI Foundation Today!

Making Healthcare Technology Safer, Together

Thank you for your support!

http://my.aami.org/store/donation.aspx

Thank you for attending!

Slides and Recording: http://www.aami.org/PatientSafety/content.aspx?ItemNumber=3694&navItemNumber=3084