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Week End Wrap Up

Learn about recent situations and plans to enhance patient safety protocols. Issues like medication errors, blood type discrepancies, linen use, printer problems, recycling tips, room stock updates, and more are discussed.

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Week End Wrap Up

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  1. Week End Wrap Up April 5, 2010

  2. Patient Safety • Situation • Pt started on Magnesium - wrong rate entered • Medication and rate reviewed by off-going and on-coming 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 • Have 2nd nurse double check rate of high risk medications at initiation (like PCAs) • Have copy of orders at bedside safety check

  3. Patient Safety • Situation • 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 • All lab data entered on triage form must be confirmed with actual lab reports

  4. Mother Baby Unit PCT • 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 30-60 minutes of shift

  5. Online Documentation Coming: Buff up or Learn Typing • 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 moreconfusing to navigate lessons) • For beginners:http://www.freetypinggame.net/free-typing-lesson.asphttp://www.sense-lang.org/typing/ • For those who want to brush up skills:http://www.davis.k12.ut.us/cjh/appliedtech/Business/Keyboarding/ • Could be accessed while at work

  6. Linen • 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 • Decrease bassinet stock of t-shirts, pads, burp cloth diapers, blankets and diapers • Provide linen to family when requested • Other ideas?

  7. Printer Problems • 5S Printer frequently doesn’t print report sheet • Causes additional hassle at end of shift • 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

  8. Other items to recycle • 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) • Those working in PCN—outer part of oral syringes recyclable if rinsed (not plunger) • Tray that Breastpump kits comes in recyclable • White trays NS syringes come in recyclable • GO GREEN !

  9. New 5S Room Stock • 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

  10. Instrument & Sponge Counts • 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

  11. Car Seats • New car seats with bases projected to be here at end of April • Cost will be $40 • Will no longer provide free car seats • Sample of new car seat now on car seat kiosk by odd hallway

  12. Cefazolin 2gm • 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!

  13. Dermatitis from hand gel? • 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

  14. Labels and PSBC • Carefully examine each label placed on forms and blood tube • Some labels cut off bit of edge—just enough to make viewing whole name difficult (or wrong) • Check each label to make sure whole name is showing • Noted as many if not more PSN reports on mislabeled tubes/no second signature/paperwork that doesn’t match etc • Getting label maker supposed to decrease number ofmistakes...not make more • Please do your own "time out" with tube and paperwork • Feel free to send me your ideas for ensuring exact paperwork and blood bank tube each and every time • Teri

  15. SCOAPSurgical Checklist • Monday, March 22nd--every hospital in Washington adopted voluntary surgical checklist for doctors and nurses to use before operating • Lead cheerleader for approach is UW surgeon David Flum • "It's preparing for difficult, preparing for unexpected. It'sbuilding 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 • “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

  16. SCOAP Surgical Checklist (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’

  17. SCOAP Surgical Checklist (Timeout) • Step 1: Prior to Induction of Anesthesia (Nursing and Anesthesia)With Patient Confirm: 􀂉 Identity 􀂉 Site and site marked (N/A) 􀂉 Procedure 􀂉 Consent 􀂉 AllergiesAnesthesia 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 procedureNursing Team Reviews􀂉 Equipment issues (e.g., all instruments ready, trained on instruments, requested implants available, gas tanks full)

  18. SCOAP Surgical Checklist (Timeout) 􀂉 Sharps management plan reviewed􀂉 Other patient concerns • 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 1hour?􀂉 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

  19. SCOAP Surgical Checklist (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)

  20. T-WingCommuter Services Office • Friday, April 16, 2010 final day of operations for T-Wing Commuter Services Office • Every department at University facing difficult choices to meet budget demands • 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 • New offices are close; quick walk across genome sciences lawn, through breezeway and across 15th • Thank you for your understanding as we work to find efficiencies that allow us to serve you better • Commuter Services prkissue@u.washington.edu 221-3701

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