2007 Safety RulesAS REAL AS IT GETS

Mike Daly BSN, Nurse ManagerDiane Vacarro MS, CNS

Florence Toy PharmDArnold Dignadice RN

Mylene Espiritu RNDaisy Cruz BSN, RN

Jignasa Pancholy RNLisa Holton RN

Celeste Arbis RN, BSNShino Honda RN, BSN

Integrated Nurse Leadership Program -- INLP• Funded by Gordon and Betty Moore

Foundation• Directed by Center of Health Professions

at UCSF• Work with Bay Area hospitals to address

issues of nurse retention and patient safety

• This year’s goal: Safety Medication Administration

This year’s participating hospitals• Kaiser Permanente, Fremont and

Hayward• Novato Community Hospital• St. Rose Hospital• Sequoia Hospital• Stanford Hospital • San Francisco General Hospital

SFGH2 Tests of Change

• Two Patient Identifiers• Interruptions during Med Pass

CalNOC Data99

87.3

47.1

85.6

65.760.8

0102030405060708090

100

Perc

ent o

f dos

es

111

Compared med withMAR

Med labed from prepto admin

Checked 2 forms ID

Explained med to pt

Charted medimmediately afteradminInterrupted duringadmin

Med Pass

• Goal: To achieve 100% patient ID check by using 2 forms

• Focus: Remind nurses to use two forms of patient identification (full name and birth date)

Med Pass Implementation

• Changes in exchange of report• Patient information stickers on

report sheet and medicine cups• Educating patients with posters

Med PassResults

Full Name and DOB Compliance Rate

90%83%

100%

68%

100% 100%

010203040506070

1 2 3 4 5 6

week

# of

pat

ient

s

0%

20%

40%

60%

80%

100%

120%

Com

plia

nce

rate

Independent vs. Dependent Double Check

Patient Controlled AnalgesiaData Collection

Interruptions

• Goal: Decrease non-urgent interruptions

• Focus: Increase awareness of interruptions which can lead to medication errors

Interruptions Definition

Non-Urgent• Non-productive

talk between nurses and other health care workers

• Non-urgent phone calls

Urgent• Calls for

immediate action or attention

Interruptions Implementation• Signs placed in hallways &

medication room• Unit clerk screens all non-urgent

phone calls• “Prevent Med Error” signs

Interruptions EvaluationTool was developed to document the types and frequency of interruptions

InterruptionsResults

Types of Interruptions

Non-Productive talk in med room,

6

Phone calls, 9

Nurse to nurse interaction, 10Other discipline

to nurse interaction, 8

Patient/family to nurse interaction,

15

No Interruptions, 11

InterruptionsResults

Location of Interruptions

Med room39%

Hallway25%

Patient's room28%

Did not state8%

InterruptionsResults

Urgency of Interruptions

Urgent17%

Non-Urgent58%

Did not state25%

Interruptions Results• Med Pass ID badge failed

• Increase in interruptions• Nurses forgot to flip the badge

• Increase in awareness among nurses and patients

• Current trial of med box

Change in Culture• Goal: Change nurses’ attitudes towards

medication administration safety

• Focus: Encourage nurses to adapt new processes

• Goal: Implement changes hospital • Wide

Safety Comes First in Medication Administration!!