Is there a Need for Immersive Workshop In Safe Medication Administration for New Anesthesia Providers?

Transcription

1 Is there a Need for Immersive Workshop In Safe Medication Administration for New Anesthesia Providers? Hideru Inoue, RN, MSN John O Donnell, DrPH, MSN, CRNA Judith Mermigas, MSN, CRNA Laura Palmer, DNP, MNEd, CRNA School of Nursing Department of Acute and Tertiary Care Nursing Anesthesia

2 Outline Is patient safety still an issue? Medication safety Workshop Development Hierarchical Task Analysis Future Directions

3 Is patient safety still an issue? To Err is Human: Building a Safer Health System ,000 deaths As many as 98,000 deaths from preventable medical errors Kohn LT, Corrigan J, Donaldson MS, Institute of Medicine (U.S.). Committee on Quality of Health Care in America. To err is human : building a safer health system. Washington, D.C.: National Academy Press; 2000.

4 Is patient safety still an issue? Preventing Medication Errors Change relationship between provider and patient Using information technologies Improved medication labeling Policy: increased funding for medication administration safety research Suggests increased training on medication administration Aspden P, Institute of Medicine (U.S.). Committee on Identifying and Preventing Medication Errors. Preventing medication errors. Washington, DC: National Academies Press; 2007.

5 Patient safety still is an issue A new, evidenced-based estimate of patient harms associated with hospital care Minimum of 200,000 lives harmed Closer to true estimate of 400,000 lives James JT. A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety. Sep 2013;9(3):

6 Background: CDC Death Rates 2o11 4 Hoyert DL XJ. Deaths: Preliminary data for National vital statistics reports. National Center for Health Statistics. 2012;61(6).

7 Background: CDC Death Rates Heron M. Deaths: Leading Causes for National vital statistics reports. National Center for Health Statistics. 2013;62(6).

8 Background: CDC Death Rates ~ 16% Heron M. Deaths: Leading Causes for National vital statistics reports. National Center for Health Statistics. 2013;62(6).

9 Patient safety still is an issue Dallas Observer April 4, 2014:

10 Medication administration errors in anesthesia No national error rate Webster et al (2001) 1:133 6 New Zeland Bowdel et al (2003) 1:130 7 USA Khan and Hoda (2005) 1:265 8 Pakistan Yamamoto et al (2008) 1:450 9 Japan Cooper et al (2012) 1: Canada

11 1:203 1:130 1:268 1:450 1:133

12 Types of errors Cooper and Nossaman (2013) Medication Error in Anesthesia: A Review 11 Incorrect dose (25 37)% Substitution (16 60)% Omission (9 21)% Cooper L, Nossaman B. Medication errors in anesthesia: a review. International anesthesiology clinics. Winter 2013;51(1):1-12.

13 How significant are medications 12 Initial morning setup ~45% Induction ~20±6% Maintenance ~15±8% Emergence ~12±7% ~30% of total activities in cardiac cases Weinger MB, Slagle J. Human factors research in anesthesia patient safety. Proceedings / AMIA... Annual Symposium. AMIA Symposium. 2001:

14 How accurate are we? 13 5oo sample syringes Experienced providers Controlled laboratory environment 59% error rate Stucki C, Sautter AM, Wolff A, Fleury-Souverain S, Bonnabry P. Accuracy of preparation of i.v. medication syringes for anesthesiology. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. Jan ;70(2):

15 Hospital care in general Prescribes APRN/MD Dispenses RN / PharmD Prepares RN / PharmD Administers RN (RN/RN) Monitors RN Documents RN Errors still occur!

16 Anesthesia: High risk profession Anesthesia Prescribes CRNA Dispenses CRNA Prepares CRNA Administers CRNA Monitors CRNA Documents CRNA Others Prescribes APRN/MD Dispenses RN / PharmD Prepares RN / PharmD Administers RN Monitors RN Documents RN Except blood products

17 How Many Rights?

18 Current status Anesthesia med errors 1:236 * Significant part of our practice Heavy reliance on human performance Questionable accuracy High risk, no oversight How are we being educated? * Average attained from studies mentioned on slide 10.

19 Current practice No guidelines from AANA No guidelines from ASA No standard from Council on Accreditation of Nurse Anesthesia Education Programs 14 U.S. Pharmacopeia Convention (USP)

20 Current practice Little to no previous dilution experience Didactic setting dosage calculations Clinical setting hands on dilutions Unsupervised, distractions Simulation hands on dilutions? Is this sufficient, can we do better?

21 Current practice As a new SRNA

22 SRNA s perspective

23 To clinical

24 At clinical

25 At clinical

26 You want to make these

27 But you have to make these

28 Your world, from this

29 To this

30 So we do this 5mg/ml

31 Learning environment

32 Medication safety workshop We know High risk Little experience Purpose: Decrease medication errors Give hand on experience pre-clinical setting

33 Medication selection Based on high-alert Clinical incident reporting Heparin (1000U/ml vs. 10,000U/ml) Ephedrine (50mg/ml 5mg/ml) Midazolam (10mg/ml 1mg/ml) Cefazolin (reconstitution) Epinephrine (1: mcg/ml 10mcg/ml)

34 Curriculum development: Hierarchical task analysis School of Nursing Anesthesia Origins: early management science 15 Increased efficiency Define training requirements Allows processes to be broken down Develop step by step instructions

35 How detailed do you need to be 16 Such that task is understood able to be performed

36 My attempt too much 1.1. Dilution of epinephrine into a fixed volume Selecting the correct medication vial Verifying correct medication name: epinephrine Verify concentration: 1:1000 or 1mg/ml Note expiration date Verify final dilution concentration Ex: Check chart, discuss with physician, refer to standard dilutions Obtain supplies Syringe 10ml Epinephrine labels Blunt-tip needle Epinephrine vial 1ml of (1mg/ml) Prepare solution Perform calculation to identify amount of epinephrine to place into final diluent volume [(AD/CA) = amount to be removed from vial or syringe] Syringe 1 = Amount Desired / Concentration Available = 100 mcg/(1000 mcg/ml) = 0.1ml of 1mg/ml epinephrine Syringe 2 = Amount Desired / Concentration Available = 10 mcg / (100mcg/ml) = 0.1 ml of 100mcg/ml epinephrine 35 steps Label syringe Syringe 1- Concentration: 100mcg/ml Syringe 2- Concentration: 10mcg/ml Date Initials Dilute medication Dilution 1 (100mcg/ml) Draw 9ml of 0.9% NaCl into 10ml syringe and add 1ml of epinephrine 1mg/ml to make 100cmg/ml of epinephrine Dilution 2 (10mcg/ml) Draw 9ml of 0.9% NaCl into 10ml syringe and add 1ml of epinephrine 100mcg/ml to make 10cmg/ml of epinephrine Store medication or identify port/site of infusion Open roller clamp Verify solution/carrier movement by verifying drops in drip chamber Clean port with EtOH (15sec) scrub the hub Attach ephedrine 10mg/ml to port Verbalize previously determined dose Administer previously determined volume Verbalize dosage administered Remove syringe

37 Faculty example better, I guess

38 Pre-workshop survey Year of practice as an RN Hospital setting: community/university Type of ICU: SICU, MICU Experience with medication dilution Previous medication errors

39 Medication safety presentation Six rights Verifying medication, concentration, expiration From medication cart Before withdrawal from vial After withdrawal

40 Medication safety presentation CDC one and Only Campaign Aseptic technique One syringe, one patient Single dose vials when possible

41 Medication safety presentation

42 Hands-on dilutions kit

43 Room set up

44 Room set up

45 Medication setup

46 Dilutions check list

47 Teaching at its best

48 Scenario for closed loop communication School of Nursing Anesthesia Mr. Smith is a 76 yr. old patient with a history of hypertension, diabetes, and CAD. He has no know allergies. He presents to the OR for a femoral-popliteal bypass. He appears anxious and apprehensive. The CRNA suggests the administration of 2.5 mg of midazolam

49 Your psychological pre-op assessment and the administration of midazolam has alleviated Mr. Smith s anxiety regarding the procedure. On the way back to the OR suite, the surgeon calls out please give my regular antibiotic.

50 Following a smooth IV induction, Mr. Smith becomes slightly hypotensive. Despite decreasing your agent, his pressure remains <20% below base line. After your assessment you decide to administer ephedrine

51 Prior to cross clamping of a major arterial vessel, the surgeon states that in a couple of minutes 4,000u of Heparin be administered. You prepare to administer the heparin.

52 The surgeon informs you that there is ongoing oozing and that he will soon be removing the arterial cross clamp. The blood pressure proceeds to drop despite the initiation of a blood transfusion. With the removal of the cross clamp the blood pressure falls precipitously. The anesthesia team decides on administering incremental doses of epinephrine.

53 Results Overall positive feedback

54 Future directions Sound familiar I do it this way Do what I say, not what I do Many ways to skin a cat When you graduate, you ll do it your way

55 Future directions Give up autonomy? 12 Aug 2008

56 5-S = Visual workspace Sort Set in order Shine Standardize Sustain

57 5-S = Visual workspace Sort Set in order Shine Standardize Sustain

58 5-S = Visual workspace Sort Set in order Shine Standardize Sustain Propofol 10mg/ml Ephedrine 5mg/ml Phenylephrine 100mcg/ml Propofol 10mg/ml Ephedrine 5mg/ml Glycopyrolate 0.2mg/ml Phenylephrine 100mcg/ml

59 Anesthesia workstations?

60 Future directions Humans replaceable? HemoBot

61 Future directions Meet your robotic anesthesia provider- Sedasys

62 Ideas Reporting/detecting error- Google glass, image recognition NSA alert Changing culture failure to report = penalty Collaboration- Data sharing between programs National trainee error database

63 Dilution charts Drug name Concentration supplies Process Final concentration Epinephrine 1:1000 (1mg/ml) 10ml syginge x2 vasopressin 20units/ml 20ml syringe Ephedrine 50mg/ml 10ml syginge Phenylephrine 10mg/ml 10ml syringe 9ml of 0.9% sodium chloride + 1ml of 1mg/ml Epinephrine 9ml of 0.9% sodium chloride + 1ml of 100mcg/ml Epinephrine 19ml of 0.9% sodium chloride + 1ml of 20Unit/ml vasopressin 9ml of 0.9% sodium chloride + 1ml of 50mg/ml Ephedrine 9ml of 0.9% sodium chloride + 1ml of 10mg/ml Phenylephrine 100mcg/ml 10mcg/ml 1 unit/ml 5mg/ml 100mcg/ml Phenylephrine (infusion) 10mg/ml 250ml 0.9% NaCl bag ketamine 50mg/ml 10ml syringe hydromorphone 2mg/ml 5ml syringe naloxone 0.4mg/ml 10ml syringe Remove 2ml from 250ml 0.9% sodium chloride + 2ml of 10mg/ml Phenylephrine into 250ml 0.9% sodium chloride 9ml of 0.9% sodium chloride + 1ml of 50mg/ml Ketamine 3ml of 0.9% sodium chloride + 1ml of 2mg/ml Hyromorphone 9ml of 0.9% sodium chloride + 1ml of 0.4mg/ml naloxone 80mcg/ml 5mg/ml 0.5mg/ml 0.04mg/ml (40mcg/ml)

64 Review Healthcare still has many safety challenges Anesthesia providers at high risk Hands-on workshop, mitigating risks

65 Thank you School of Nursing Anesthesia

66 References 1. Kohn LT, Corrigan J, Donaldson MS, Institute of Medicine (U.S.). Committee on Quality of Health Care in America. To err is human : building a safer health system. Washington, D.C.: National Academy Press; Aspden P, Institute of Medicine (U.S.). Committee on Identifying and Preventing Medication Errors. Preventing medication errors. Washington, DC: National Academies Press; James JT. A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety. Sep 2013;9(3): Hoyert DL XJ. Deaths: Preliminary data for National vital statistics reports. National Center for Health Statistics. 2012;61(6). 5. Dallas Observer April 4, 2014: 6. Webster CS, Merry AF, Larsson L, et al. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001;29: Bowdle TA. Drug administration error from the ASA Closed Claims Project. ASA Newsl. 2003;67: Khan FA, Hoda MQ. Drug related critical incidents. Anaesthesia. 2005;60: Yamamoto M, Ishikawa S, Makita K. Medication errors in anesthesia: an 8-year retrospective analysis at an urban university hospital. Journal of Anesthesia 2008; 22: Cooper L, Digiovanni N, Schultz L, et al. Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anaesth. 2012;59: Cooper L, Nossaman B. Medication errors in anesthesia: a review. International anesthesiology clinics. Winter 2013;51(1):1-12.

67 References 12. Weinger MB, Slagle J. Human factors research in anesthesia patient safety. Proceedings / AMIA... Annual Symposium. AMIA Symposium. 2001: Stucki C, Sautter AM, Wolff A, Fleury-Souverain S, Bonnabry P. Accuracy of preparation of i.v. medication syringes for anesthesiology. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. Jan ;70(2): Standard for Accreditation of Nurse Anesthesia Edcuational Programs. Park Ridge, Illinois: The Council on Accreditation of Nurse Anesthesia Educational Programs; Stanton NA. Hierarchical task analysis: developments, applications, and extensions. Applied ergonomics. Jan 2006;37(1): Piso E. Task analysis for process-control tasks: The method of Annett et al. applied. Journal of Occupational and Organizational Psychology. December 1981;54(4):7.