Transcript Week End Wrap Up

Week End Wrap Up
April 5, 2010
Patient Safety
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Situation
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Pt started on Magnesium - wrong rate entered
Medication and rate reviewed by off-going and oncoming RN @ bedside
On-coming nurse did not double check written order
for several hours
Discovered medication at 2 grams/hour instead of
ordered dose of 1 gram/hour
Magnesium level drawn
Assessment: Too much Magnesium infused
Plan
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Have 2nd nurse double check rate of high risk
medications at initiation (like PCAs)
Have copy of orders at bedside safety check
Patient Safety
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Situation
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Perinatal Triage form lists Mom's blood type O+
Verbal report indicates Mom O+
Mother Baby Studies desired due to potential for
ABO incompatibility
Cord blood not collected
Provider plan to order newborn blood draw
Provider explaining to family need for blood draw
Mom reports she is B+
PSBC records confirm B+
Assessment: Near miss
Plan
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All lab data entered on triage form must be
confirmed with actual lab reports
Mother Baby Unit PCT
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Recent survey revealed much
information re PCT use—thank you
to those who participated
Feedback being given to PCTs
Success of care model improves
with “huddle” of RNs and PCT
partner all together within first 3060 minutes of shift
Online Documentation Coming:
Buff up or Learn Typing
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MANY free online typing tutorials
Best one found so far that is useful for all skill levels: free,
but staff must set up login and password to use:
http://www.typingweb.com/
Other sites don't require setting up account (but slightly more
confusing to navigate lessons)
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For beginners:
http://www.freetypinggame.net/free-typing-lesson.asp
http://www.sense-lang.org/typing/
For those who want to brush up skills:
http://www.davis.k12.ut.us/cjh/appliedtech/Business/Keyboardin
g/
Could be accessed while at work
Linen
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March 2010 highest linen use for hospital
in years
Increase = $40,000 more in cost
Please think twice about linen placed in
room—everything is considered soiled at
discharge
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Decrease bassinet stock of t-shirts, pads, burp
cloth diapers, blankets and diapers
Provide linen to family when requested
Other ideas?
Printer Problems
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5S Printer frequently doesn’t print report sheet
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Causes additional hassle at end of shift
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First solution—charge RN logs on to computer at
shift beginning and logs out at shift end
At some point in “log on” printer stops being
responsive to that individual
Second solution—make sure document queue for
printer is clear
IT services says this will keep system working
Other items to recycle
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Gel bottles of Aavagard when empty can be rinsed, top
thrown away and put in recycle bin (do not put them
on MM cart, they just throw them away)
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Those working in PCN—outer part of oral syringes
recyclable if rinsed (not plunger)
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Tray that Breastpump kits comes in recyclable
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White trays NS syringes come in recyclable
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GO GREEN !
New 5S Room Stock
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Head of bed cupboard (has BP manometer, O2,
suction) now has containers with: 4 -10 cc
saline flushes, 4 - 2x2s, 4-6 alcohol wipes,
tape, 4 - bandaids, 4 red IV caps and adult
regular BP cuff
PCTs will stock with room set up
Due to high loss of flashlights when stored in
patient rooms, plan to keep in med room
cupboard—please help prevent loss by
returning to med room after use
Instrument & Sponge Counts
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Primary circulating RN counts with scrub tech
If permanent change in either scrub or circulator
(eg. shift change) , needs to be another count of
instruments and sharps/sponges at time of
change
2nd RNs do not count instruments or sponges
(error on 0-30-60 posters will be fixed)
2nd RN can place foley, help anesthesia, etc
Car Seats
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New car seats with bases projected to be
here at end of April
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Cost will be $40
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Will no longer provide free car seats
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Sample of new car seat now on car seat
kiosk by odd hallway
Cefazolin 2gm
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Cefazolin 2gm now available in
6S(APS) pyxis
Total of 6 unmixed doses readily
availiable in event of zero C/S
Four in 6E pyxis and two in 6S
pyxis.
Thanks to Roger Dean!
Dermatitis from hand gel?
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Experience bad dermatitis from
hand gel?
Encouraged go to Employee Health
and get seen
Have hand gel alternatives that
have helped people with alcohol
dermatitis
Labels and PSBC
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Carefully examine each label placed on forms and blood tube
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Some labels cut off bit of edge—just enough to make viewing
whole name difficult (or wrong)
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Check each label to make sure whole name is showing
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Noted as many if not more PSN reports on mislabeled tubes/no
second signature/paperwork that doesn’t match etc
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Getting label maker supposed to decrease number of
mistakes...not make more
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Please do your own "time out" with tube and paperwork
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Feel free to send me your ideas for ensuring exact paperwork and
blood bank tube each and every time
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Teri
SCOAP
Surgical Checklist
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Monday, March 22nd--every hospital in Washington adopted voluntary
surgical checklist for doctors and nurses to use before operating
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Lead cheerleader for approach is UW surgeon David Flum
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"It's preparing for difficult, preparing for unexpected. It's
building safety layer in, instead of relying on our own memories to
avoid mistakes,” says Flum. "People can’t be perfect, but systems can
strive for perfection. That's what we're trying to build in here."
MIC began implementation 4/1
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“Timeout" checklist abbreviated version in main OR
Done with nursing, anesthesia and OB attending
With all surgeries (except absolute "0" emergencies just splash and cut)
Checklist behind door in OR1 and on wall in OR2
SCOAP Surgical Checklist
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(Timeout)
Please use Checklist - located back of OR door
(DR1) or Wall (in DR 2)
No documentation necessary at this time (will
document once ORCA here)
Final Verification document still used (may
transition out with ORCA)
Nursing, Anesthesia or Surgeon may call for each
step, if not done by docs, RN calls for checks
Sharps Management: surgeon should state
‘procedure will be completed using utmost
concern for sharps safety’
SCOAP Surgical Checklist
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(Timeout)
Step 1: Prior to Induction of Anesthesia (Nursing and Anesthesia)
With Patient Confirm: 􀂉 Identity 􀂉 Site and site marked (N/A) 􀂉 Procedure 􀂉 Consent
􀂉 Allergies
Anesthesia team confirms: 􀂉Anesthesia Machine Ready 􀂉 Patient position
􀂉Airway/aspiration risk assessment completed 􀂉 If increased risk, needed equipment
available, plan described
Step 2: Briefing—Prior to Skin Incision (All Team Members)
􀂉 Team members introduce themselves by name and role
􀂉 Surgeon, Anesthesia, Nurse: Confirm Patient (at least 2 identifiers), Site, Procedure
􀂉 Personnel exchanges discussed (timing of and plan for announcing exchanges)
Anesthesia Team Reviews
􀂉 Concerns (airway, special meds [beta blockers], relevant allergies, conditions
affecting recovery, etc)
Surgeon Reviews
􀂉 Brief description of procedure and anticipated difficulties 􀂉 Expected duration of
procedure
􀂉 Need for instruments/supplies beyond those normally used for the procedure
Nursing Team Reviews
􀂉 Equipment issues (e.g., all instruments ready, trained on instruments, requested
implants available, gas tanks full)
SCOAP Surgical Checklist
(Timeout)
􀂉 Sharps management plan reviewed
􀂉 Other patient concerns
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Step 3: Process Control—Prior to Skin Incision (Surgeon Leads)
􀂉 Essential imaging displayed, right and left confirmed 􀂉N/A
􀂉 Antibiotic prophylaxis given in last 60 minutes 􀂉 N/A
􀂉 Case expected to be less than 1
hour?
􀂉 Yes (proceed with operation)
􀂉 No (follow arrow to right) → CASE EXPECTED TO BE LONGER
THAN 1 HOUR:
􀂉 Active warming in place
􀂉 Glucose checked for diabetics
􀂉 Insulin protocol initiated if needed
􀂉 DVT/PE prevention plan in place
􀂉 If patient on beta blocker, post-op plan formulated
􀂉 Re-dosing plan for antibiotics
􀂉 Specialty-specific checklist
SCOAP Surgical Checklist
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(Timeout)
Step 4: Debriefing—At Completion of Case (All Team Members)
􀂉 (Surgeon and Nursing) Before closure: Are instrument, sponge, and
needle counts correct?
􀂉 (Surgeon and Nursing) If a specimen, confirm label and instructions
(e.g. orientation,12-lymph nodes for colon CA)
􀂉 (All) Confirm name of procedure
􀂉 (All) Equipment issues to be addressed? 􀂉 No 􀂉Yes, and response plan
formulated (Who/When)
􀂉 (All) What could have been better? 􀂉 Nothing 􀂉Something, with plan to
address (Who/ When)
􀂉 (Surgeon and Anesthesia) Key concerns for recovery (e.g., plan for pain
management, nausea/vomiting)
T-Wing
Commuter Services Office
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Friday, April 16, 2010 final day of operations for T-Wing Commuter
Services Office
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Every department at University facing difficult choices to meet budget
demands
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Identified consolidation of sales and administrative services to single
location important step to lowering overhead while providing streamlined
services
New location in Portage Bay Parking Facility, able to meet all needs for
commuting products and services Monday through Friday from 7:30AM to
5PM
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New offices are close; quick walk across genome sciences lawn, through
breezeway and across 15th
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Thank you for your understanding as we work to find efficiencies that allow
us to serve you better
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Commuter Services
[email protected]
221-3701