Hospital-wide Lean Project: Reducing the number of ADE s related to High Alert Medications Patrice Chatterton, RNC, CPHQ Donna Berning, BS, RN, MS, CPHQ
Agenda Slide What is lean? What does the training/project entail? Why did we choose to focus on high alert medications? What is our current work related to the project? Fifth Agenda 2 July 1, 2013
What is Lean? Lean methodology Focuses on process vs. outcome Looks into reducing waste in processes to add value Solutions come from the people doing the work (front-line staff) 3 July 1, 2013
Why did we choose Adverse Drug Events? 4 July 1, 2013
Why did we choose high alert medications? 5 July 1, 2013
Breakdown of the HAMP Errors (3 years) 44% of HAMP errors associated with heparin 2012: Improvement work conducted on heparin gtt process 28% of HAMP errors associated with insulin 6 July 1, 2013
7 July 1, 2013 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
What is our current work related to the project? -Understand the Current Process- Strengths What do you like about the HAMP verification process? Weakness What do you think needs to be improved with the current process? 8 July 1, 2013
-Understand the Current Process- Opportunities What opportunities do you think should be taken advantage of? Threats What could hinder the performance of this process or interrupt this service? 9 July 1, 2013
-Understand the Current Process- Observations on the Unit (Gemba) Process Flow Charts 10 July 1, 2013
Obtain CBG RN #1 sign into KPHC 2 Pt Identifier RN #1 scan Pt ID band RN #1 locate Med on MAR (verify order) RN #1 click on Autocal link RN #1 enter CBG in Autocal RN #1 vocera s RN #2 RN #1 wait for RN #2 response RN #1 hits calculate in Autocal RN #1 minimize Autocal on screen RN #1 open Doc Flowsheet in KPHC RN #1 click on POCT tab RN #1 add column with correct time RN #1 enter CBG into POCT Flowsheet RN #1 enter Autocal column into POCT flowsheet (optional) RN #1 travel from WOW to IV pump RN #1 enters new gtt rate & volume into pump RN #1 verifies right drug, dose, and route (tracing lines) at pump 6.5 min RN # 2 arrives to conduct verification RN #1 reports CBG to RN #2 RN #2 maximizes Autocal on screen RN #2 reviews Autocal calculations RN #2 submits calculation in Autocal Confirmation screen pops up, RN#2 to verify and confirm by clicking ok RN #2 closes Autocal RN #2 enters gtt rate from Autocal into POCT flowsheet RN #2 signs as 2 nd verifier RN #2 travel from WOW to IV pump RN #2 verifies right drug, dose, and route (tracing lines) at pump Insulin administered at correct rate
Risk Insulin Verification Risk & Frequency Chart High Incorporate Autocal into KPHC (eliminate additional program) Simplify and Standardize Verification Process Device Integration (CBG downloaded into POCT Flow sheet) Decrease wait time of 2 nd verifier by assigning shift buddies Auto add column for current time in KPHC Low Equipment layout in room position computer and pump next to each other (same side of room) Low Frequency High
2 Pt Identifier Future State Process Flow Chart
Risk Insulin Verification Risk & Frequency Chart High Unable to correct per KPHC Provide a safe, standardized process with simplified checklist (RIM #1) Incorporate Autocal into KPHC (eliminate additional program) Simplify and Standardize Verification Process To come at a later date Include report out of events in Safety Huddles (RIM #2) Establish Buddy System (RIM #3) Device Integration (CBG downloaded into POCT Flow sheet) Staff to see value in verification process; communicate events to increase awareness Decrease wait time of 2 nd verifier by assigning shift buddies Low To come at a later date Establish most efficient equipment setup in room to decrease travel time during verification (RIM #4) Auto add column for current time in KPHC Equipment layout in room position computer and pump next to each other (same side of room) Low Frequency High
Alert assigned buddy of need for 2 nd verifier RN #1 sign into KPHC 2 Pt Identifier RN #1 scan Pt ID band RN #1 locate Med on MAR (verify order) RN #1 click on Autocal link located on MAR Obtain CBG RN #1 enter CBG in Autocal RN #1 clicks calculate in Autocal RN #1 clicks submit in Autocal. (DO NOT CLICK OK IN CONFIRMATION WINDOW) Alert RN #1 verifies right drug/concentration hanging and programs pump per Autocal calculations (rate and volume) Alert RN #1 traces IV tubing 1. from bag to pump 2. from pump to patient (Note: Insulin line to infuse into port of maintenance line closest to patient ) RN #1 minimize Autocal on screen RN #1 open Doc Flowsheet in KPHC RN #1 click on POCT tab RN #1 enter CBG into POCT Flowsheet RN #1 enter Autocal column into POCT flowsheet RN #1 enter rate into POCT flowsheet and moves verification box to side of screen to allow RN #2 to view RN # 2 arrives to conduct verification RN #2 maximizes Autocal on screen RN #2 verifies CBG from glucometer matches CBG entered into autocal RN #2 reviews Autocal calculations RN #2 clicks OK in confirmation window in Autocal RN #2 closes Autocal Alert RN #2 verifies right drug/concentration hanging and confirms pump programed correctly per Autocal calculations (rate and volume) Alert RN #2 traces IV tubing 1. from bag to pump 2. from pump to patient (Note: Insulin line to infuse into port of maintenance line closest to patient ) RN #2 presses start on pump after all calculations and IV set up are found to be correct RN #2 signs as 2 nd verifier Insulin administered at correct rate Target State Process Flow Chart
RIM #1 - Sample Checklist Primary RN: Verify right drug and concentration hanging Program pump (rate & volume) per algorithm Trace IV tubing: Bag to Pump Pump to Patient (Note: If drug calls for carrier fluids, carrier fluids should connect directly to Pt IV with drug tubing connected into carrier fluids at port closest to patient) Secondary RN: Verify right drug and concentration hanging Confirm pump (rate & volume) programmed correctly per algorithm -For Insulin gtts: confirm CBG from glucometer matches CBG entered in Autocal -For Heparin gtt: confirm aptt is most recent result Trace IV tubing: Bag to Pump Pump to Patient Confirm proper IV set up (see note above) After all pump programming and IV set up are found to be correct, press start on pump
RIM #2 - Increased Communication and Reporting Creating a standardize list for morning huddles setting expectations of information to escalate to senior leadership which will include HAMP errors Nursing Manager Director Senior Leadership Alert sent out on huddle findings for immediate house wide learning Nursing Manager Director Senior Leadership Hospital ALERT
RIM #3 Shift Buddies Help facilitate safe care Cut down on hand over's Create climate of teamwork Decrease wait time for nursing processes Improve efficiency
RIM #4 - Reduce Room Traffic Decrease amount of travel time required to perform verification process Standardizes the flow process Improve efficiency in process Allows RN to have more direct patient care time
Table Computer Table Before Standardization Pump Patient Bed 1 st RN 2 nd RN Current room set-up both the 1 st RN and 2 nd RNs foot steps necessary to perform Independent Verification Process
Table Computer Table After Standardization Patient Bed 1 st RN 2 nd RN Standardize room set-up decreases both the 1 st RN and the 2 nd RN foot steps necessary to perform Independent Verification Process
Questions? 22 July 1, 2013