Improving Patient Safety for Patients on Opioid Medication Revising the Verification Process Lynn Anson, RN-BC, Kathlyn Baharaeen, RN, BSN, CCRN, Elizabeth Edmundson, RN, BSN, Michele Fix, RN, BSN, Jenny Marsh, RN, BSN, CPON, Holly Mc Farland, RN, Kelly O’Neill, RN, BSN, CPON, Janis Smith, RN, DNP, Janet Sollazzo, RN, BSN, CPN, Carrie Tyner, RN, BSN, CPN ASPMN 20th National Conference September 22 - 25, 2010 Minneapolis, Minnesota The need for medication safety is paramount for all patients, especially those prescribed opioids in the pediatric population. Electronic documentation can play a substantial role in safe administration practices, however, caution must be taken to assure that the clinical practice components essential to safety are not lost in the transition. New Process & Policy New Process/ Policy Need for Change Education Plan Evaluation An education plan was developed and implemented to disseminate information about the new process including: Nursing Resource Guide videos that nurses could access on-line on the hospital web-based nursing site. These short 1 minute videos outlined each of the three verification process scenarios with actual demonstration of the process. Live demonstrations with detailed explanations and rationales for the new process were presented by team members at all inpatient unit updates. Process instruction cards were laminated and attached to all PCA and Epidural pumps and posted in all medication rooms for quick and easy recall. Emails and newsletters outlining the new process and the reasoning behind these changes were sent to all nurses, nurse managers and nurse educators at the institution. After education was completed, nurses were required to take a web-based test with 100% passing rate to assure knowledge and understanding of the process. Rationales were provided as an added teaching method for missed questions. An auditing process was developed to determine the effectiveness, nursing compliance and need for further education that is currently ongoing. Widespread problems with the institutions’ wireless computer access have caused setbacks in the implementation and nursing acceptance of the new verification process. These issues are currently being addressed at the administrative level with plans to continue forward towards increasing nursing compliance with the verification process. References: 1.D'Arcy, Y. (2008). Keep your patient safe during PCA. Nursing 2008, January, p. 51-55. 2.Institute for Safe Medication Practices (2007). Reducing patient harm from opiates. ISMP Medication Safety Alert, 12(4), p. 1-3. Hewett,B.L.,&Ehmann,C.(2003). In Smarthinking Writer’s Handbook, Chapter 3, Lesson 24, Proofreading Strategies, retrieved from http://www.smarthinking.com/static/document_library. Contact information: Lynn Anson, RN-BC at lanson@cmh.edu. Problem: One Midwest pediatric hospital recently implemented a new electronic documentation system. By design, two registered nurse signatures were required for opioid waste verification. However, two signatures for verifying dosages and pump programming were no longer required as was previous practice. Although two nurses were still needed to do this verification, many nurses misunderstood the lack of signature requirement as no need for a verification check at all. Utilizing PCA incident reports, the institution's PCA Task Force identified that most PCA errors could have been prevented with proper verification by two nurses. Previous Process: Independent double checks wherein two nurses each looked at orders and medication/pumps separately or together. This was a variable process across inpatient units. Verification confirmed with both nurses initialing settings on a paper MAR (Medication Administration Record). This process was not optimal because: 1. Nurses may see what they think the order or pump is thought to be, not what it actually is. 2. Nurses may be complacent and not physically look at the orders and pump but take the other nurses' word that it is all correct and sign MAR anyway. 3. Order revisions missed as nurses may not print the most recent order to use during verification. In August 2008, a subcommittee of the institution's Nursing Practice Council consisting of pain management nurses, direct care nurses, nurse educators and administrative representatives, examined the current process, conducted a literature review and formulated an improved verification process for PCA/Epidural infusions and high risk medication administration.1,2 New Process: No longer an independent double check, verification now involves each nurse verbalizing either the orders or pump components to each other in a designated sequence to reduce misread errors.3 Shift Change & Transfer of Care Blind Double Check Handoff RN: Pull up patient’s current PCA/Epidural order on Electronic MAR. Receiving RN: Read syringe/bag content and each pump setting out loud. Handoff RN: Verify and read each of the order components out loud. Receiving RN: Verbalize the amount remaining in the syringe and on the pump. Handoff RN: Confirms amount remaining. Receiving RN: Documents appropriate information in patient electronic record. PCA/Epidural Initiation, Order Change and Bolus Dose Blind Double Checks Primary RN: Pull up the order on computer and program pump to correct settings. Witnessing RN: Read each detail of the pump settings to Primary RN out loud (read syringe/bag content with initiation or syringe/bag changes). Primary RN: Read each detail of the order from computer to Witnessing RN out loud. Primary RN: Press button to start infusion. Primary RN: Document on Electronic MAR (no witness signature is required). High Risk Medication Double Check Verification (PO/IV) Primary RN: pulls up order on computer obtains medication and checks 5 rights (patient, medication, dose, route, time) checks Electronic MAR for last time medication given hands medication to witnessing RN for verification documents medication administration on Electronic MAR Witnessing RN: independently looks at order on computer verifies medication with 5 rights same as above gives medication to Primary RN for administration documents witness signature on Electronic MAR only with wasted medication Poster Prepared by: Michelle Moser, Administrative Coordinator, CMH&C