1. 2007 Safety Rules AS REAL AS IT GETS Mike Daly BSN, Nurse Manager Diane Vacarro MS, CNS Florence Toy PharmD Arnold Dignadice RN Mylene Espiritu RN Daisy Cruz BSN, RN Jignasa Pancholy RN Lisa Holton RN Celeste Arbis RN, BSN Shino Honda RN, BSN

2. Integrated Nurse Leadership Program -- INLP Funded by Gordon and Betty Moore Foundation Directed by Center of Health Professions at UCSF Work with Bay Area hospitals to address issues of nurse retention and patient safety This year ’ s goal: Safety Medication Administration

3. This year ’ s participating hospitals Kaiser Permanente, Fremont and Hayward Novato Community Hospital St. Rose Hospital Sequoia Hospital Stanford Hospital San Francisco General Hospital

4. SFGH 2 Tests of Change Two Patient Identifiers Interruptions during Med Pass

5. CalNOC Data

6. Med Pass Goal: To achieve 100% patient ID check by using 2 forms Focus: Remind nurses to use two forms of patient identification (full name and birth date)

7. Med Pass Implementation Changes in exchange of report Patient information stickers on report sheet and medicine cups Educating patients with posters

8. Med Pass Results Compliance rate

9. Independent vs. Dependent Double Check Patient Controlled Analgesia Data Collection

10. Interruptions Goal: Decrease non-urgent interruptions Focus: Increase awareness of interruptions which can lead to medication errors

11. Interruptions Definition Non-Urgent Non-productive talk between nurses and other health care workers Non-urgent phone calls Urgent Calls for immediate action or attention

12. Interruptions Implementation Signs placed in hallways & medication room Unit clerk screens all non- urgent phone calls “ Prevent Med Error ” signs

13. Interruptions Evaluation Tool was developed to document the types and frequency of interruptions

14. Interruptions Results

17. Med Pass ID badge failed Increase in interruptions Nurses forgot to flip the badge Increase in awareness among nurses and patients Current trial of med box

18. Change in Culture Goal: Change nurses ’ attitudes towards medication administration safety Focus: Encourage nurses to adapt new processes Goal: Implement changes hospital Wide

19. Safety Comes First in Medication Administration!!