2007 Safety Rules AS REAL AS IT GETS

1. 2007 Safety RulesAS 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 JignasaPancholyRN 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. SFGH2 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 PassImplementation • Changes in exchange of report • Patient information stickers on report sheet and medicine cups • Educating patients with posters

8. Med PassResults Compliance rate

9. Patient Controlled AnalgesiaData Collection Independent vs. Dependent Double Check

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

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

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

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

14. InterruptionsResults

15. InterruptionsResults

16. InterruptionsResults

17. Interruptions Results • 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!!