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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
0
10
20
30
40
50
60
70
80
90
100
Per
cent
of
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%
0
10
20
30
40
50
60
70
1 2 3 4 5 6
week
# o
f p
ati
en
ts
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 Evaluation
Tool 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, 10
Other 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!!
