TJC Corrective Actions Nursing Education January, 2015
TJC Finding Normal Saline fluids stored in the warmer did not have the revised expiration dates. Normal Saline fluids stored in the warmer had a temperature monitor log that indicated the appropriate temperature range for the storage of linens, not fluids.
WFBMC Policy Blankets and solutions will be warmed in separate, dedicated compartments. Solutions can only be warmed for specified durations according to the product manufacturer. When placed in the warming cabinet, solutions should be labeled as Do not re-warm and with a remove by date, which is the date the solution is to be removed from the warmer. Solution warmer temperatures should not exceed 104 F and should be recorded once daily on the Solution Warmer Temperature Log. Refer to policy: Blanket and Solution Cabinet Warmers
Solution bags should be in their overpouches when in the warming cabinet Solutions in plastic bags (overpouch) Warm for 14 days Cannot be re-warmed after 14 days Label as Do not re-warm Discard after manufacturer s labeled expiration date Irrigation solutions in plastic pour bottles Warm for 60 days Discard after 60 days in warmer Labels can be obtained from Clinical Compliance and Regulatory Services DO NOT RE-WARM REMOVE BY:
TJC Finding Laboratory reported a critical test result to the nurse in a timely manner; however, there was no documentation to indicate the nurse had notified the LIP of the critical result.
WFBMC Policy The individual taking the critical result will notify the provider within 15 minutes of receiving the result(s) and record in the Provider Notification flowsheet in WakeOne : Step 1. Click on Doc Flowsheets and go to the Assessment Flowsheet. Step 2. Click on Provider Notification in the table of contents (towards the bottom). Refer to policy: Critical Results of Tests and Diagnostic Procedures Policy
TJC Finding It was discovered that there were opened multidose vials of Labetalol and Hydralazine located in patient medication bins without an expiration date. SEA #52 Preventing Infection from the Misuse of Vials
WFBMC Policy When a multi-dose vial is opened, it should be labeled with a 28 day beyond-use date unless a shorter expiration date is specified in the manufacturer s insert. Refer to policy: Management of Multidose and Single Dose Vials
Corrective Action Plan: 28-Day Expiration Date Calendars will be Posted in Medication Rooms
Current Situation: Pharmacy places a yellow sticker on insulin vials and pens upon removal from the refrigerator. In this case the 28-day beyond use date represents the date of removal from the refrigerator and not the date of first use. Pharmacy places a white label on Labetalol vials. In this case the white label is used to cover up the manufacturer s pre-printed label which prompts the nurse to write the 28-day beyond use date upon opening.
Corrective Action Plan Pharmacy is purchasing new yellow labels that will be used on all multidose vials. Insulin (vials and pens) will be predated with 28- day beyond use date by pharmacy upon removal from refrigerator. Date will have month/date/year. (Process will begin as soon as new labels are received.) The same label will be placed on other multidose vials for the nurse to date with the 28-day beyond-use date upon opening. Staff Education
Proposed New Labels:
TJC Finding During review of the medical record, the progress notes indicated the physician instructed the nurse to stop the Propofol infusion and start Precedex. The patient became agitated and the Propofol infusion was resumed. The physician had not written the orders to stop or hold the Propofol or under what parameters to resume it and stop the Precedex. (There was verbal discussion regarding parameters.) Verbal orders should only be accepted in emergent situations or when provider does not have ready access to a computer. Refer to policy: Medication Use Processes
TJC Finding Physician order was for Oxycodone 5 mg for mild pain, 10 mg for moderate pain, and 15 mg for severe pain. On two occasions the nurse administered 15 mg oxycodone for moderate pain.
WFBMC Policy PRN orders: Orders acted on based on the occurrence of a specific indication or symptom. All orders must be prescribed with a specific dose, frequency, and indication.. All concerns, issues, or questions are clarified with the individual prescriber before dispensing the medication.. Healthcare staff may administer medications consistent with law, regulation, and hospital policy, and within the scope of their individual license or certification... Educational Note: If a nurse assesses the patient s needs as outside of order parameters, the nurse must contact the provider for a new order or to clarify before administration. Refer to policy: Medication Use Processes
Corrective Action Plan: Standardization of the 10-Point Pain Scale numeric value assigned to low, moderate, and severe pain across the organization. Pain Management Policy: 1. Mild pain: (1-3) 2. Moderate Pain: (4-6) 3. Severe Pain: (7-10) Order sets to be updated to include standardization of the 10-Point Pain Scale numeric value assigned to low, moderate, and severe pain. Staff Education
TJC Finding Pain reassessments documented beyond the one hour reassessment criteria of the organizational policy.
WFBMC Policy Revision Reassessment of pain intensity and pain relief is performed at regular intervals. The same pain intensity rating scale used for assessment should be used for reassessment. The patient's response should be assessed within one hour of any pharmacological intervention. Nonpharmacological interventions should be assessed with the next scheduled assessment of patient unless additional interventions are required. Educational Note: Documentation of assessment/reassessment should occur as close to real time as possible, but must be completed by the end of shift (column to be added to DocFlow sheet to record actual time of assessment and/or reassessment if not documented in real time). Any incomplete reassessments at handoff should be completed by the nurse before going off duty. Refer to policy: Pain Management
Assessment Reminder Tools in WakeOne
Assessment Reminder Tools in WakeOne Work List Tasks
Assessment Reminder Tools in WakeOne Nurses can go directly from the MAR to their Flowsheet to chart.
Corrective Action Pain Management Policy reviewed and revised to clarify that pharmacological interventions would be reassessed within one hour, and that non-pharmacological interventions would be reassessed with next scheduled patient assessment unless additional interventions were required. Charge Nurse or their delegate to review patients on unit prior to end of shift to ensure pain reassessments are completed by nursing staff. Education
TJC Finding Observed in multiple locations: No evidence of completed code cart inventory and defibrillator operator s checklist for each shift and/or when on-call cases were held
Corrective Action Plan Code Blue Plan policy revisions: Use of Zoll Defib Dashboard to monitor defibrillator checks Checklists simplified and updated to reflect DAILY checks Manager/Coordinator/Supervisor responsible for ensuring cart/defib checked DAILY and before beginning on-call cases
TJC Finding Eyewash Stations On multiple inpatient units, eyewash logs were reviewed. It was noted that several documentation lapses had occurred.
Corrective Action Plan A Risk Assessment is being done by Environmental Health and Safety to determine if the number of eyewash stations could be reduced in non-essential areas. Eyewash Stations in the clinical areas should be checked on a weekly basis, with water flowing for 3 minutes. (Standardized day of the week Eye Wash Wednesday!) Weekly checks are documented with the date and person s initials. The eyewash log is now being revised to make it easier to use. Environmental Services will continue to check all eyewash stations in the locked EVS closets.
TJC Finding Oxygen Tanks On one unit, an oxygen tank was found to be free standing and unsecured, posing a risk for tipping and potential injury. In multiple units/departments, empty oxygen tanks (red zone or less that 500 PSI) were found in the rack designated for Full tanks.
Corrective Action Plan Oxygen Tanks All cylinders must be secured in an oxygen tank rack, rolling cart or other appropriate device. Signage will be *changed so that the oxygen storage racks will read either: Empty (in the red zone,<500 PSI, <1/4 full) In Use (tanks above 500 PSI or >¼ full) Continue to check PSI before patient use.
TJC Finding Using Proper PPE During an observation, an employee was seen cleaning an endoscope without goggles or a face shield. The nurse was wearing her regular eye glasses at the time. Expired Supplies On multiple units, expired medical supplies were found.
Corrective Action Plan Using Proper PPE Eye glasses do not act as personal protective equipment. During high level disinfection cleaning and other high risk procedures, you must wear goggles or a face shield. Expired Supplies Review all medical supplies in the par stock areas on a monthly basis, and rotate stock items so that the older items are used first.
Completion You have completed this required education. Please contact Clinical Compliance and Regulatory Services for questions/concerns.