Conference Report Published by CareFusion Center for Safety and Clinical Excellence
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- Bu səhifədəki naviqasiya:
- Challenges in heparin administration
- Need for protocol use
- Improving VTE prophylaxis
- Improving ADE reporting
- Figure 1. Physicians Brain on Protocol
- New Admission! Mrs. Smith fell Angry patient wants "real doctor" LOOK GOOD ON ROUNDS
- Heparin best practices
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A perfect storm for errors Currently nursing is in the midst of a perfect storm for heparin errors. There is an unprecedented combination of factors that greatly increase the probability of poten- tially life-threatening errors. One of the condi- tions creating this circumstance is the nursing PROCEEDINGS Executive Summary Conference Report
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shortage that affects many practice settings in the United States, including the medical- surgical and critical care units where heparin is frequently used. Nurses are challenged by higher patient acuity, unrelenting pressures to decrease cost and improve patient out- comes and increasingly complex therapies with high-risk medications. Human factors further affect the potential for error. Nurses work in restricted, congested spaces with high traffic and frequent inter- ruptions. They must master a growing num- ber of new, complicated technologies, work longer hours and manage professional and personal distractions 1,2 .
The combination of these demands can often exceed the ability of even highly experienced nurses to function without error. Ensuring the safety of highly complex heparin administration requires a multidisci- plinary approach. Unfortunately, literature on the nurse’s perspective in safe heparin admin- istration is limited; therefore, the following discussion is based on anecdotal reports and personal experience.
The first challenge nurses face when administering heparin is look-alike labels. Until recently, vials containing 10,000 units/ mL and those vials containing 10 units/mL had labels that closely resembled each other. Confusion between labels was one of fac- tors leading to heparin errors in infants that resulted in mortality and morbidity. Manufacturers have changed prod- uct labels to enhance visual differentiation between the two concentrations by nurs- ing and pharmacy staff, but poorly labeled vials may still remain in hospital inventories. Therefore, hospitals must implement mea- sures to ensure that vials of highly concen- trated heparin are kept only in the hospital pharmacy and not stocked in patient care areas 7,8
. A second challenge is the complexity of cal- culating heparin infusion dose rates. Variable physician practices and lack of standardized protocols further increase the potential for error. A nurse might have two patients on heparin receiving different concentrations and/or different dosages based on weight- based or non-weight-based protocols. Within weight-based dosing protocols, practitioners may disagree on which weight to use in dos- age calculations—current, admission or “dry” weight—further increasing nursing staff con- fusion. Nurses are inconsistently taught to double-check heparin dosages before admin- istration and, even when correctly taught, inconsistently perform this practice because of time constraints. Many nurses are not highly skilled in dose calculations and find the com- plex calculations required for heparin dosage adjustments challenging 9 . A third challenge is obtaining and doc- umenting a patient’s weight 10 . Determining the patient’s weight often is not consistently ordered or consistently performed. Staff may rely on patients to self-report their weight, which may be incorrect. Staff members do not always know the correct use and calibra- tion of scales. Errors may occur in recording weights as pounds or kilograms. If these units of measures are confused, significant under or overdosing of heparin may occur and result in a serious adverse drug event. A fourth challenge is posed by the imple- mentation of new smart pump (computerized infusion) technology with dose-error-reduc- tion software. Smart pumps assist nurses by providing dosage limits and warnings when doses are outside these limits. The nurse performs a series of entries to program the pump. If the dose programmed into the pump exceeds pre-established limits in the pump’s database, the safety software generates an alert that must be addressed before infusion can proceed, thus helping to avert a potential error. When faced with competing priorities, a nurse has a perceived “need for speed” and may bypass the safety features offered by the pump
11 . Both Rothschild 12 and Keohane 13
found that the use of smart pump technol- ogy is beneficial in identifying errors but had no impact on the serious error rate in their facilities. Both authors concluded that this technology requires systematic implementa- tion and continued follow-up to prevent clini- cians from having to circumvent or bypass the safety system. A fifth challenge is the lack of standard- ized heparin protocol. Most institutions allow a prescriber to individualize each order when prescribing heparin. This leads to variation in dosage (weight-based versus non-weight- based), titration schedules (every four hours, six hours and others) and monitoring pro- tocols (timing and laboratory parameters). Because of shortages in nursing staffing, agency and floating nurses are often used. These nurses encounter variation both within and among facilities. Lack of standardization increases the likelihood of making incorrect assumptions or incorrect entries. A sixth challenge is the recognition of heparin-related complications. The two pri- mary complications of heparin therapy are over-anticoagulation and heparin-induced thrombocytopenia (HIT). A nurse is in the unique position of being the last step in the medication therapy process and the person who monitors the patient. Most nurses are well educated to monitor for over-anticoagu- lation but many are not educated to monitor for HIT. Detection of HIT can be challenging because of unpredictability and the use of heparin throughout acute care. Nurses car- ing for patients should be educated about these complications for all patients receiving either unfractionated heparin or low molecu- lar weight heparin 14,15 to prepare them for both over-anticoagulation and HIT. 53
Executive Summary Conference Report 9th Invited Conference: Improving Heparin Safety Conclusion Nurses have a critical role in the safe use of heparin. The nurse must work as a full partner of a multidisciplinary team and advo- cate for a learning culture to prevent errors, for nurses’ rights in heparin administration and, most importantly, for patient safety to be a priority for all practitioners. Other team members must respect nurses and listen to their concerns and observations. Without this partnership, consistently error-free heparin treatment cannot be realized.
1. Mayo AM, Duncan D. Nurse perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qual 2004 Jul-Sep;19(3):209-17. 2. Tucker AL, Spear SJ. Operational failures and interrup- tions in hospital nursing. Health Serv Res 2006 Jun;41(3 Pt 1):643-62. 3. Pape TM. Applying airline safety practices to medica- tion administration. Medsurg Nurs 2003 Apr;12(2):77- 93; quiz 4. 4. Cook M. Nurses' six rights for safe medication adminis- tration. 2008 [cited 2008 February 23]; Available from: http://www.massnurses.org/nurse_practice/sixrights. htm
5. Hatcher I, Sullivan M, Hutchinson J, et al. An intrave- nous medication safety system: preventing high-risk medication errors at the point of care. J Nurs Adm 2004 Oct;34(10):437-9. 6. Schneider PJ. Applying human factors in improving medication-use safety. Am J Health Syst Pharm 2002 Jun 15;59(12):1155-9. 7. Institute for Safe Medication Practices. Another hepa- rin error: Learning from mistakes so we don't repeat them. 2007 [cited 2008 February 23]; Available from: http://www.ismp.org/Newsletters/acutecare/arti- cles/20071129.asp?ptr=y 8. Jennings J, Foster J. Medication safety: just a label away. AORN J 2007 Oct;86(4):618-25. 9. Matthew L. Injectable medication therapy: a patient safety challenge. Nurs Stand 2007 Apr 11-17;21(31):45-8. 10. Hilmer SN, Rangiah C, Bajorek BV, et al. Failure to weigh patients in hospital: a medication safety risk. Intern Med J 2007 Sep;37(9):647-50. 11. Fields M, Peterman J. Intravenous medication safety system averts high-risk medication errors and provides actionable data. Nurs Adm Q 2005 Jan-Mar;29(1):78-87. 12. Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medica- tion safety in critically ill patients. Crit Care Med 2005 Mar;33(3):533-40. 13. Keohane CA, Hayes J, Saniuk C, et al.. Intravenous medication safety and smart infusion systems: lessons learned and future opportunities. J Infus Nurs 2005 Sep- Oct;28(5):321-8. 14. Cooney MF. Heparin-induced thrombocytopenia: advances in diagnosis and treatment. Crit Care Nurse 2006 Dec;26(6):30-6; quiz 7. 15. Valenstein PN, Walsh MK, Meier F. Heparin monitoring and patient safety: a College of American Pathologists Q-Probes study of 3431 patients at 140 institutions. Arch Pathol Lab Med 2004 Apr;128(4):397-402.
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PROCEEDINGS
• An evidence-based heparin protocol can help to standardize and guide heparin dosage and adjustments. • A venous thromboembolism (VTE) prevention protocol, which included order sets, real time patient identification and intervention increased the percent of patients with adequate VTE prophylaxis from 50% to 98% over a two-year period resulting in decreased rates of VTE and pulmonary embolism (PE). • Active surveillance for adverse drug events (ADE) associated with heparin and other medi- cations using rescue medication / pharmacist and laboratory triggers identifies far more events than relying on billing codes and voluntary reporting alone. • Physician compliance with heparin safety measures can be improved by involving physi- cians when the anticoagulation management protocol is developed and ensuring the pro- tocol is efficient and user-friendly. Using Heparin Safely: A Hospitalist Perspective Ian Jenkins, MD, Hospitalist, University of California San Diego, San Diego, CA
An evidence-based heparin protocol can be straightforward (Figure 1). So, why do physicians, especially interns and residents, not comply with it? One explanation is that physicians are overloaded because of distrac- tions, interruptions and competing demands (Figure 2). A distracted physician can easily fail to adjust a heparin infusion, notice that a patient who is being treated with heparin has developed new thrombocytopenia or check renal function before choosing an anticoagu- lant. The highly complex clinical environment is a reality that must be addressed to improve heparin safety. The aviation industry is recognized for low error rates and an excellent safety culture that promotes doing things right and speaking up if something is wrong. Each pilot is not expected to develop, or even recall, preflight safety checks before each take off; a check- list is already standard procedure. Similarly, physicians should not have to remember all of the details involved in decisions about the optimal monitoring, product, dose, fre- quency of administration and duration for each course of anticoagulation. Evidence- based information should be incorporated into a protocol that standardizes and guides heparin dosage and adjustments. Aviation safety principles are based on the fact that pilots cannot evaluate informa- tion on an entire instrument panel to detect a minor abnormality. Pilots need warning lights. Physicians also need alerts, such as alerts for newly developing thrombocytope- nia or for a history of heparin-induced throm- bocytopenia (HIT), a condition which may occur with a normal platelet count or may be hidden in the past medical history, but not be listed as an allergy, and may therefore be easy to overlook.
At the University of California San Diego (UCSD), as at most medical centers, a large majority of inpatients are at risk for deep vein thrombosis (DVT) and pulmonary embo- lism (PE) and can benefit from subcutaneous heparin to reduce their risk. In January 2007, a baseline assessment showed that only 50% to 55% of patients received appropriate VTE prophylaxis; the VTE rate was 13.4/1000 patients. The baseline assessment highlight- ed the need for a hospital-wide VTE prophy- laxis protocol. A team of physicians, pharmacists, and programmers developed a VTE prophylaxis order set that employed a simple, three- tiered risk assessment tool. The first page of the computerized order set requires a physi- cian to assess a patient as high, moderate, or low risk for VTE and included a link to a table of VTE risk factors. The second page prompt- ed the prescriber to consider both absolute (e.g., active hemorrhage) and relative (e.g. cirrhosis) contraindications for prophylactic heparin therapy, as well as other conditions such as HIT or the presence of an epidural catheter. Based on the patient’s risk level and the 55
Executive Summary Conference Report 9th Invited Conference: Improving Heparin Safety presence or absence of contraindications, the protocol provided a suggested regimen on the third page. Most commonly, this included a subcutaneous heparin when not contrain- dicated, as well as intermittent compression devices for patients who were at high risk or unable to take pharmacologic prophylaxis. This screen also displays safety reminders, such as a warning that enoxaparin should not be used if there is renal insufficiency, and that dose reductions in unfractionated hepa- rin (UFH) should be considered for small or elderly patients. Compliance was ensured by mandating use of the protocol for all inpatient admis- sions and transfers. Implementation of the order set was followed by surveillance and real time alerts for patients who appeared to be untreated, but eligible for prophylaxis. These situations prompted notification of the treating physicians that VTE prophylaxis could be considered.
During a two-year period, the percent of patients with adequate VTE prophylax- is increased from 50% to 98% (Figure 3). Preventable VTE decreased more than 80% and the total VTE rate was almost cut in half. The PE rate decreased from 4 to about 1.2 per 1,000 patients (Figure 4). Investigators also sought to determine whether treatment had caused any harm. A retrospective review of service codes for sec- ondary thrombocytopenia was conducted to determine the rate of HIT. A review of about 50,000 charts showed a relative risk of about 1.44, which was not significant. Evaluating the risk of bleeding, a rela- tively rare event, led to another concern. Wein found that the relative risk of bleeding is about 1.5 for UFH and not significant for low molecular weight heparin [LMWH] 1 . After implementing the order set, analysis of a sam- ple population at UCSD found no bleeding events when reviewing anticoagulant-related adverse drug events (ADE). This observation raised the question of whether voluntary reporting and physician billing data provide trustworthy information on these events.
Intermountain Healthcare in Salt Lake City suggests that billing codes and voluntary reporting do not adequately reflect the real rate of ADEs. Their quality improvement team sought to determine how many ADEs could be detected with passive compared to active surveillance. During a period of time when a voluntary reporting system identified six ADEs (none serious), encouraging staff to report ADEs by making the system easy to use and protecting them from punishment identified 60 events. Lastly, a full-time phar- macist reviewed the use of antidotes, rescue medications and critical laboratory test results to identify patients whose charts should be reviewed to determine whether these events were the result of an ADE. For example, in the case of heparin-related complications, use of protamine or argatroban would suggest an adverse event. This active surveillance indenti- fied 481 new ADEs 2 . When a passive search for ADEs is conducted, the result is often a false sense of security based on inaccurately low reported ADE rates—and opportunities to care for affected patients and prevent future complications are lost. In the case of the VTE prophylaxis protocol, an aggressive search for Figure 1. Physician's Brain on Protocol Identify heparin indication Check allergies, baseline labs Order correct, weight based product Monitor and adjust per protocol
Discharge Mr. Jones urinate > daily Grand rounds in 10 min! Coffee deficiency Salvage marriage Check ptt, adjust UFH gtt Check GFR before DVT ppx Notice low plts on exaparin RN calling about colace Conference presentation Call rheum consult Follow duty hours Discharge prescriptions New Admission! Mrs. Smith fell Angry patient wants "real doctor" LOOK GOOD ON ROUNDS FINISH NOTES BEEP! BEEP!
BEEP! BEEP!
BEEP! Review medications Why is Nunez altered?
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HIT complicating heparin therapy indentified more than 500 patients tested or treated for HIT, and preliminary analysis suggests that confirmed HIT was both exceedingly rare and not associated with use of the protocol, con- firming its safety with regard to the develop- ment of HIT. Heparin best practices Despite a robust VTE prevention program, community and hospital acquired VTE still occurs, and usually results in a prolonged course of anticoagulation which can be com- plex and risky to administer. A UCSD evi- dence-based VTE protocol (Table 1) has been developed and is in the process of being implemented that incorporates evidence- based guidelines and standards from the Joint Commission on Hospital Accreditation. Selected components of this protocol include obtaining proper baseline laboratory tests, overlapping heparins with warfarin for at least five days (including two therapeutic INR mea- surements), patient education, timely labora- tory and clinic follow-up, use of UFH when patients have a creatinine clearance less than 30, protocol-based UFH infusions and warfa- rin loading regimens, and long-term LMWH treatment for eligible patients with cancer. A grant-funded study will analyze the results of protocol implementation. As with the VTE prevention protocol, the ultimate goal is a user-friendly but thorough CPOE order set that makes it easier for physi- cians to make good decisions and more diffi- cult to make mistakes. It may take six to eight months to develop CPOE order sets. While these are being developed, interim measures can be used such as paper versions of the pro- tocol, staff education, and nursing protocols. Pharmacy collaboration is crucial, as it offers a chance to review orders before medica- tion is delivered to the patient, ensuring that issues such as drug/warfarin interactions are addressed before patient harm can occur. One warning light already in place is the reporting of a calculated eGFR with every creatinine, which can alert doctors to the presence of renal failure when age or malnutrition blunts the elevation of creatinine levels. Yüklə 1 Mb. Dostları ilə paylaş:
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