1. 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 , 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.
s 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
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
Contact information:
Lynn Anson, RN-BC at
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