Raising the Bar On Infusion Safety: A Patient Safety Program at Baylor Scott & White Health Improving Infusion Pump Safety: A Systematic Approach

Transcription

1 Raising the Bar On Infusion Safety: A Patient Safety Program at Baylor Scott & White Health Improving Infusion Pump Safety: A Systematic Approach July 18, 2016

2 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 NEW Compendium: Opioid Safety & Patient Monitoring National Coalition for Alarm Management Safety NEW Compendium: AAMI Foundation Management of Clinical Alarm Please Consider Making a Donation! Contact Marilyn Flack at mflack@aami.org

3 A Special Thanks

4 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. Diamond Platinum Gold

5 LinkedIn Questions Please post questions on the AAMI Foundation s LinkedIn page. OR Type a question into the question box on the webinar dashboard.

6 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. 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 ). 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.

7 Polling Questions

8 Speaker Introductions Molly A. Hicks, RN, MSN Director of Patient Safety, Baylor Scott & White Health Jason Trahan, PharmD Pharmacy Director Medication Safety, Baylor Scott & White Health

9 Improving Infusion Pump Safety: A Systematic Approach July 18, 2016

10 None Disclosures

11 Presentation Outline Background Compliance Library Optimization Alerts Overrides Edits Good Catches Alert Effectiveness Library Content Sustainment Lessons Learned 9/25/

12 Baylor Scott & White Health More than 900 patient care sites including 48 hospitals 5.1 million patient encounters annually More than 40,000 employees More than 6,000 affiliated physicians Scott & White Health Plan $9.7 billion in total assets $7.5 billion in total operating revenue 12

13 Project Background Between December 2005 February 2013 BSWH launched over 4,000 smart pumps in 12 facilities November 2012 Executive report from vendor indicated very low compliance with the dose error reduction systems (DERS) and high number of over ride alerts Historical data for implementation, training, policy, and quality data was limited No systematic approach for assessing metrics or communicating the benefit of DERS system

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15 Strategies to Address Interdisciplinary team formed and charged with the following: Improve Utilization of the Pump Library Increase patient safety (Program Edits = Good Catches) Decrease the number of Alert Overrides (Alert Fatigue) 9/25/

16 Project Team Project Team ROLE Executive Sponsor Co-Team Leads Team Members Ad-Hoc members TITLE VP of Patient Safety / CPSO Director, Patient Safety Pharmacy Director- Medication Safety Director of Human Factors Clinical Technology Team Lead VP Nursing Operations VP Nursing Workforce VP of Professional Development Director of Clinical Nursing Excellence Vendor Clinical Nurse Consultant Vendor Pharmacy Consultant Staff nurses / managers for specialty councils 4

17 Human Factors Identified Barriers to Compliance Programming errors data entry & calculation Usability of the pumps Takes too long to program Not familiar with key steps in using the pumps Usability of the drug library Commonly used drugs not easily located Items not descriptive / intuitive Common doses not included in library Too many alerts Organization support No clear expectation about using the drug library No organized ways to learn

18 Process Modeling Fishbone Diagram

19 Lack of Drug Library Optimization Resulted In: High numbers of over rides and alerts and alert fatigue 22.3% overall rate of ALERTS / 100 programs 21.3% overall rate of OVER RIDES / 100 programs 60% of all alerts were from ten ISMP drugs Low number of drugs with hard limits Only 23% of the drugs had hard upper limits (HUL) Only 0.2 % of the drugs had hard lower limits (LUL) No scheduled library updates or owner No on-going formal process to access drugs

20 Rapid Cycle Methodology Overview Identify opportunities for improvement Identify barriers to use Identify best practices Target ISMP High Risk drugs 1 st Plan vendor report was source of problem identification Do several rapid cycle changes Reviewing a set of drugs Schedule drug library updates Remove non-formulary drugs Remove unused library CCA System-wide retraining Creating generic antibiotic selections System goals set and shared Champions identified Spread Good Catches Facilities developed improvement teams Act after reviewing the results Check - Monthly reports Share results w/ leaders and users Review feedback from users s

21 Sharing and Spreading Communicate Results and Findings: To leadership, CNO s, managers, nursing councils Enhance communication to pharmacy leaders Post results in central location on system intranet site Discuss at specialty councils: Patient Safety Officers, Risk Managers, Professional Development, Critical Care Share at Safety and Best Care meetings Metrics added to the monthly dashboard report Set up address for users to provide feedback On going dialogue with vendor to benchmark with other national users

22 SAMPLE REPORTS

23 Infuser Drug Library Install Status SITE PUMP CHANNELS Report LIBRARY INSTALLED % INSTALLED Facility A % Facility B % Facility C % Facility D % Facility E % Facility F % Facility G % Facility H % Facility I %

24 Monthly Compliance Report by Facility by CCA* Facility A B C D E F G H I J K L TOTALS *Clinical Care Area=CCA

25 GOOD CATCH REPORT

26 Good Catch Report Good catches or saves: Potential programming errors avoided by using the drug library. Human factors: Being more careful is NOT sufficient. # of errors prevented from reaching patients in April 2016 for selected drugs: Facility Medication A B C D E F G H I J K L Total Dexmedetomidine Insulin Heparin Amiodarone Rapid LD Nicardipine 20 mg/200ml Diltiazem Fentanyl Norepinephrine Max Con Amiodarone 1.8 mg/ml Potassium Phosphate Norepinephrine STND Nicardipine 40mg/200 ml

27 Graph of Library Utilization 9/25/ % 35.0% 40.0% 45.0% 50.0% 55.0% 60.0% 65.0% 70.0% 75.0% 80.0% 85.0% 90.0% 95.0% 100.0% Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16

28 Library Optimization Overrides - Alert Fatigue. Edits - Good Catches Initial Process to address - Alignment Review of Standard Order Sets EHR Review Limit Evaluation Data Use; Evidence Based Medicine 9/25/

29 Alerts Process Developed Identify top 10 override alerts per quarter Review EHR Order Sets Review Organizations standard medication reference Adjust limits based on data 9/25/

30 Rate of ALERTS per Programs 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 7.60% Alerts Programs 1 QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR % 1.00% 0.00% 1 QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR % 1 QTR - 16 TAKE HOME: Avoided 73,582 nuisance alerts in first QTR 2016 from baseline 9/25/

31 Rate of EDITS per Programs 0.90% 0.80% 0.70% 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% 0.00% 0.47% 1 QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR % 4 QTR - 1 QTR Edits Programs 1 QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR TAKE HOME: Additional 4,176 errors avoided in first QTR 2016 from baseline 9/25/

32 Alert Effectiveness 40.00% 35.00% 30.00% 25.00% 20.00% Edits Alerts 1 QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR % 10.00% TAKE HOME: Baseline 1 edit to every 17 Alerts 5.00% 0.00% 1 QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR - 16 Last QTR 1 edit to every 2.8 Alerts 9/25/

33 Pump Library Contents Shared account created for direct feedback Established processes for: Set updates quarterly aligned with EHR updates Adding new medications as approved by Pharmacy and Therapeutics Committee Surveys and Meetings with frontline nurses Standardization of Concentrations/Preparations Identifying specialty councils for pump library ownership Change in order of appearance for high use medications.

34 Compliance is up and alert overrides are going down but are we safer?

35 100.0% 80.0% 17.1 Journey of Infusion Safety - BSWH/NTX Compliance increased by 129% and alerts 528% more effective Resulting in 217% more errors were avoided # of Errors Avoided Compliance to Drug Library Use Alerts effectiveness (# of alerts per avoided error) % % % % 0

36 Sustainment Sustainment Hardwiring the improvement : Include Pump training with focus on why during orientation, Provide elearning option, just in time review Shift Huddles / rounding, Ongoing sharing of data with leaders, users, and committees Performance goals by CCA (i.e. Critical care, ED, etc.) Super user huddles started Created short demo videos Sharing good catch reports to front line staff Process Owners: Being defined by role / facility and assigning Receiving update to the pump CCA drug list Drug limits Running reports Orientation 16

37 Next Steps \ Lessons Learned Next Steps / Lessons Learned Next PDCA Cycle: Identify the most frequently used drugs by CCA Optimize pump screens so top 10 drugs are on the first screen Train facility person to run Med Net Data Develop can report to provide facilities routinely / automatic Reduce number of nuisance alarms Lessons Learned Through the Improvement Process: Communication for keeping users informed real time of compliance. Present data in a simple fashion Identify best practices among facilities and share Unintended consequences with software updates Unintended consequences of drug library optimization Ongoing support for facility teams to problem solve and maintain high compliance and engagement 18

38 ADDITIONAL RESOURCES 9/25/

39 9/25/

40 Thank you for attending! Slides & Recording Available Here

41 Future/Ongoing Initiatives 9/25/

42 CE Credit See Follow-Up ! 9/25/

43 Mark Your Calendars! August 8, 2016; 12pm to 1pm Another in our series: Raising the Bar on Infusion Therapy Safety Patient Safety Initiatives at Western Maryland Health System and Cameron Memorial Community Hospital CE credit of 1 hour has been approved for this seminar

44 Complimentary Resources Safety Innovations Series Alarms Management Patient Safety Seminars Seminar Recordings Webinar Slides Key Points Checklists NEW Opioid Safety & Patient Monitoring NEW AAMI Foundation Alarm Compendium

45 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. Diamond Platinum Gold

46 Questions? Post a question on AAMI Foundation s LinkedIn Type your question in the Question box on your webinar dashboard Or you can your question to: mflack@aami.org.

47 Consider Making a Donation to the AAMI Foundation Today! Making Healthcare Technology Safer, Together Thank you for your support!

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: 18