QI: Allergy Error

Laura ChampionNicole Chan

Andrew Bierman Barbara Lacuesta

July 1st, 2015

Background

❖ Patient AG is a 62 year old male with a history of stent placement x3, atrial fibrillation, and enlarged left atrial appendage.

❖ Patient at Cath Lab for a watchman placement procedure

❖ Patient identified to have latex allergy in pre-op. Red allergy band placed on patient's wrist.

❖ Op nurse #1 retrieved the patient; full hand-off recieved from pre-op nurse

❖ Allergy was identified in the handoff to Op nurse #1

Problem❖ At operation room, Op Nurse #1 along with Op

Nurse #2 transferred patient on to operation table. No information about the patient was exchanged between the two nurses.

❖ Nurse #1 left the room, while Nurse #2 prepped the patient and began to insert Foley Catheter

❖ Foley Catheter would not insert; Nurse #2 swapped out Foley tip for a Coude tip. Original Foley tip did not contain latex, but the Coude tip contained Latex.

❖ Patient had localized reaction (minor swelling and erythema around the head of the penis and meatus) to the latex containing Coude Catheter.

❖ Nurse #1 Failed to communicate Allergy; Nurse #2 failed to identify allergy either with patient or by reviewing the red allergy band.

Red Flags❖ A failure to communicate crucial patient

information from Op Nurse #1 to Op Nurse #2.

❖ A failure of Nurse #2 to identify the Allergy.

➢ Failure of nurse to check patient identifiers for allergy

➢ Failure of nurse to check for allergies with patient directly by asking patient

Policy/Protocols

Staff Dynamics & Environment

Manpower & Staffing Roles

Materials

Exposing patient to Allergy

Ineffective communication between the two Op nurses (both ways)

Nursing roles within the Op room may be ambiguous.

Lack of policy/protocols requiring that all crucial patient information be communicated to Op room staff by the hand off receiving nurse, prior to that nurse leaving the patient

Fast paced/high volume environment

Lack of policy/protocol requiring handoff receiving nurse remain with the patient at all time

Nurse #1 left room without informing of patients allergy.

Nurse #2 failed to identify patient’s allergy by not following safety protocol (EMR, patient bracelet, or patient directly).

Foley Catheter tip did not contain latex, while the coude catheter did contain latex.

Nurse #2 came from a hospital that had no latex containing products

Nurse #1 may not have known the other nurse was inserting a catheter.

Nurse #2 failed to insert the Foley catheter the first time.

Two nurses in the Op room may be unnecessary. If one nurse is enough to adequately staff, then communication errors between nurses would decrease.

Root Cause Analysis

❖ Failure to Communicate (Primary Failure)

➢Nurse #1 failed to communicate the patient's crucial information pertinent to prepping the patient for the procedure

➢Nurse #2 failed to communicate to Nurse #1 by requesting crucial information about the patient

➢Nurse #2 failed to communicate to the patient by asking the patient if he had any allergies.

❖ Protocol Failure on Nurse #2 (Secondary Failure)

➢Nurse #2 failed to follow hospital protocol of checking patient identifiers for crucial information (i.e. allergies) prior to performing any prepping procedure (i.e. insertion of Foley Catheter).

Root Cause Analysis

OR Nurse #1 failed to communicate the patient allergies to OR Nurse #2

OR Nurse #2 failed to assess for patient allergies per protocol

Coude catheter containing latex used

Patient has known allergy to latex

Rash on Penis

Patient experienced allergic reaction

Problem: ❖ Harm inflicted on patient due to lack of

communication between healthcare providers. ❖ Lack of pre-op protocol ensuring patient safety

PLANEnsure Patient Safety

DODevelop Patient Protection

Policies in the OR

ACTImplement New

Policy/Procedures

STUDYEvaluate Effectiveness of New

Policy

PDSA

PDSA: Aim

What are we trying to accomplish?❖ To increase patient safety in

the OR by creating a dual time-out policy prior to operative procedures, thus decreasing adverse effects within six months of policy implementation and utilization

PDSA: PlanTasks Person

responsible

When Where

Create a policy that enforces a dual timeout in the OR. Policy to include a preoperative time-out upon initial arrival of patient prior to any medication administration. Secondary time-out immediately post medication administration prior to operative procedure

Stakeholders including but not limited to physicians, RNs, administrators, nursing educators, professional associations, state accrediting agencies

Within 3 months Operating Room

Introduce new policy to stakeholders Education department Upon finalization of policy

Education

Educate OR staff on new dual timeout policy, including RNs, surgical techs, anesthesiologists, and physicians

Education Department, RNs, surgical techs, anesthesiologists and physicians

Upon creation of new policy

Education

Implement new policy into patient care RNs, surgical techs, anesthesiologists and physicians

Immediately after training is completed

Operating Room

Evaluate effectiveness of policy through decreased adverse patient events in OR

RNs, surgical techs, anesthesiologists and physicians

6 months after implementation

Operating Room

PDSA: PlanTasks Prediction Measures to detect

prediction success

Create a policy that enforces a dual time-out protocol in the OR. Policy to include a preoperative time-out upon initial arrival of patient prior to any medication administration. Secondary time-out immediately post medication administration prior to operative procedure

The policy describes a dual timeout protocol including pre-prep timeout as well as preoperative time-out. Pre-prep time-out to include patient, RNs, surgical techs, anesthesiologists and physicians. To be implemented prior to medication administration.

Policy is approved and included in the Policy Book

Introduce new policy to Operating Room staff

At least 90% of RNs, surgical techs, anesthesiologists and physicians will be receptive to new policy within one week of policy finalization

Sign-in sheet at each training meeting

Educate OR staff on new dual timeout policy, including RNs, surgical techs, anesthesiologists, and physicians

At least 90% of OR staff including RNs, surgical techs, anesthesiologists and physicians will complete and verbalize the importance of new policy within two weeks of receiving policy education

Sign-in sheet at each training meeting

Implement new policy into patient care OR staff will utilize dual timeout protocol for each surgical procedure within two weeks of policy implementation

Documentation of pre-prep timeout and preoperative time-out for each surgical patient

Evaluate effectiveness of policy Reduced number of adverse patient occurrence in OR

PDSA: Do

● It will take approximately 3-4 months for the new protocol to be implemented into regular practice

● Pre-prep time out and pre-op time will be documented on EMR

● Patient surveys distributed on discharge will be analyzed to verify accuracy of new protocol implementation documented on EMR

● Incident reports in the OR will also be reviewed to determine efficacy of policy

● Staff feedback will be gathered throughout implementation

PDSA: Study

Prediction OutcomeThe policy describes a dual timeout protocol including pre-prep timeout as well as preoperative time-out. Pre-prep time-out to include patient, RNs, surgical techs, anesthesiologists and physicians. To be implemented prior to medication administration.

Approximately 95% of documentation shows implementation of policy occurred prior to medication administration .

At least 90% of RNs, surgical techs, anesthesiologists and physicians will be receptive to new policy within one week of policy finalization

Approximately 75% of RNs, surgical techs, anesthesiologists, and physicians were receptive to new policy within one week of implementation.

At least 90% of OR staff including RNs, surgical techs, anesthesiologists and physicians will complete and verbalize the importance of new policy within two weeks of receiving policy education

80% of OR staff reported new policy as important within two weeks

OR staff will utilize dual timeout protocol for each surgical procedure within two weeks of policy implementation

90% of surgical procedures utilized dual time-out protocol

Reduced number of adverse patient occurrence in OR No significant changes in number of adverse patient events occurred in OR

PDSA: Study Problem Solution

Approximately 75% of RNs, surgical techs, anesthesiologists, and physicians were receptive to new policy within one week of implementation (opposed to 90% predicted).

Create incentives for staff to be more receptive to new protocol, ie. catered lunches for highest policy implementation scores on patient surveys

No significant changes in number of adverse patient events occurred in OR.

Extend implementation and surveillance period an additional 6 months (low occurrence of adverse events in OR may contribute to lack of significant data) as well as introduce exclusion criteria for emergent cases (allergy/past medical history is not always available for pre-prep and pre-op timeout)

❖ Summary of findings: The new protocol was not successful at significantly reducing the number of adverse patient events in the OR. Our aim was to increase patient safety in the OR by creating a dual time-out policy prior to operative procedures, thus decreasing adverse effects within six months of policy implementation and utilization. The 6 month time frame for implementation may not have been long enough to collect significant data. Additionally, exclusion criteria, as noted above, may control external variables and provide more accurate data. Creating incentives for staff may also increase receptiveness of policy implementation.

PDSA: Act

Next steps – what will you recommend as a result of your small test of change?

The new protocol of a pre-prep and pre-op time out will be incorporated into new OR staff training so that all incoming OR staff will be informed of proper protocol. Implementation of new protocol will be continued for an additional six months, then re-evaluated for effectiveness.

Stakeholder AnalysisInternal (unit) stakeholders● Nurses● Managers● Anesthesiologists● Nurse anesthetists● Surgical techs● Surgeons

External stakeholders

● Patients

● Patient families

● Hospital shareholders/donors

● Health care workers in other units pt. may be transferred to

● Educators

● Administrators

● Professional associations

● Accrediting agencies

Force Field Analysis

New hospital/unit policy

Preventative nature

Repercussions for failure to follow

Quick and easy

Time restraints

Limited staff receptiveness

Does not apply to emergencies

Create a dual time-out policy prior to operative procedures, thus decreasing adverse effects. Documentation made on EMR to verify pre-prep and pre-op time outs. Patient surveys used to double-check accuracy of EMR documentation.

Forces FOR Change (Driving Forces)

Forces AGAINST Change(Resisting Forces)

Patient compliance

ReferencesAmerican Nurses Association (2013). Patient safety: A shared responsibility. Online Journal of Issues in Nursing Vol 8(3). Association of periOperative Registered Nurses (2015). Guidelines for Perioperative Practice. Retrieved from: http://www.aorn.org/guidelines/ Joint Commission International Center for Patient Safety. (2007). Strategies to improve hand-off communication: Implementing a process to resolve questions. Retrieved from: http://www .jcipatientsafety.org/15274/

Ludwick S. Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb. Available from: http://www.ncbi.nlm.nih.gov/books/NBK20546/.

Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing: Theory and application (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.