2.50
Hdl Handle:
http://hdl.handle.net/10755/163866
Category:
Abstract
Type:
Presentation
Title:
Consistent Care = Safe Care
Author(s):
Harne-Britner, Sarah; Fowler, Kimberly
Author Details:
Sarah Harne-Britner, RN, MSN, CCRN, Pinnacle Health System, Harrisburg, Pennsylvania, USA, email: nacnsorg@nacns.org; Kimberly Fowler, RN, MSN
Abstract:
Statement of the Problem: JCAHO reports that 15.75% of all sentinel events are medication errors. Most errors are at the point of administration, but are also due to complex delivery systems, work design, environmental factors and human error. Purpose: The Clinical Nurse Specialist (CNS) in our newly merged healthcare system identified that documentation of heparin infusions varied. A system-wide documentation tool was developed that included the heparin rates/boluses and PTT results. Significance: Pinnacle Health System's two acute care hospitals have >1000 heparin infusions/year. Intravenous heparin is regulated by medically approved guidelines in which a sliding scale directs the bedside nurse to adjust the heparin infusion based on the most current PTT result. System-wide audits revealed that three different methods for documenting the infusion were utilized. Of greater significance was a determination that on all units evidence of variance from the guidelines existed. The CNS, in conjunction with the Nurse Practice Council (NPC), determined that this inconsistency was of grave importance for patient safety. A Description of the Practice Change: The CNS and NPC, which is comprised of one staff nurse from each nursing unit, facilitated the following practice change in December 2001. The standard Medication Administration Record (MAR) was creatively transformed into a dedicated heparin MAR. June 2002, nursing began using the heparin MAR to record heparin rate changes/boluses, PTT results and time of the next PTT. The information on the heparin MAR was also readily available to all members of the healthcare team. The CNS supported the NPC & clinical education committee in system-wide nursing and unit secretary education. Evaluation: Prior to implementation of this practice change, documentation was lacking on 50% of the clinical records. In many records it was impossible to assure that the infusion guidelines were being followed and 33% of the charts deviated from the guidelines. System-wide audits at 6 months and 1-year revealed 100% compliance with the heparin infusion guidelines. At 1 year, only 3 records revealed errors in the timing of the PTT following a heparin bolus. Implications for Practice: This project supports the statement that consistent care assures safe care. Of equal importance, the process of the heparin infusion project demonstrated that the NPC is an effective decision-making body that can influence nursing practice. The CNS encouraged the unit-based nurses to let go of tradition and seek new directions to improve patient safety and quality care. The success of this project motivated the staff to address other medication safety issues at our organization - insulin infusions, consistency in patient identification and the process of medication administration.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2004
Conference Name:
2004 NACNS Conference, Renaissance in CNS Practice: Transforming Nursing in the 21st Century
Conference Host:
NACNS - National Association of Clinical Nurse Specialists
Conference Location:
San Antonio, Texas, USA
Description:
Conference theme: Renaissance in CNS Practice: Transforming Nursing in the 21st Century, held on March 11 to 13, 2004 in San Antonio, Texas, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleConsistent Care = Safe Careen_GB
dc.contributor.authorHarne-Britner, Sarahen_US
dc.contributor.authorFowler, Kimberlyen_US
dc.author.detailsSarah Harne-Britner, RN, MSN, CCRN, Pinnacle Health System, Harrisburg, Pennsylvania, USA, email: nacnsorg@nacns.org; Kimberly Fowler, RN, MSNen_US
dc.identifier.urihttp://hdl.handle.net/10755/163866-
dc.description.abstractStatement of the Problem: JCAHO reports that 15.75% of all sentinel events are medication errors. Most errors are at the point of administration, but are also due to complex delivery systems, work design, environmental factors and human error. Purpose: The Clinical Nurse Specialist (CNS) in our newly merged healthcare system identified that documentation of heparin infusions varied. A system-wide documentation tool was developed that included the heparin rates/boluses and PTT results. Significance: Pinnacle Health System's two acute care hospitals have >1000 heparin infusions/year. Intravenous heparin is regulated by medically approved guidelines in which a sliding scale directs the bedside nurse to adjust the heparin infusion based on the most current PTT result. System-wide audits revealed that three different methods for documenting the infusion were utilized. Of greater significance was a determination that on all units evidence of variance from the guidelines existed. The CNS, in conjunction with the Nurse Practice Council (NPC), determined that this inconsistency was of grave importance for patient safety. A Description of the Practice Change: The CNS and NPC, which is comprised of one staff nurse from each nursing unit, facilitated the following practice change in December 2001. The standard Medication Administration Record (MAR) was creatively transformed into a dedicated heparin MAR. June 2002, nursing began using the heparin MAR to record heparin rate changes/boluses, PTT results and time of the next PTT. The information on the heparin MAR was also readily available to all members of the healthcare team. The CNS supported the NPC & clinical education committee in system-wide nursing and unit secretary education. Evaluation: Prior to implementation of this practice change, documentation was lacking on 50% of the clinical records. In many records it was impossible to assure that the infusion guidelines were being followed and 33% of the charts deviated from the guidelines. System-wide audits at 6 months and 1-year revealed 100% compliance with the heparin infusion guidelines. At 1 year, only 3 records revealed errors in the timing of the PTT following a heparin bolus. Implications for Practice: This project supports the statement that consistent care assures safe care. Of equal importance, the process of the heparin infusion project demonstrated that the NPC is an effective decision-making body that can influence nursing practice. The CNS encouraged the unit-based nurses to let go of tradition and seek new directions to improve patient safety and quality care. The success of this project motivated the staff to address other medication safety issues at our organization - insulin infusions, consistency in patient identification and the process of medication administration.en_GB
dc.date.available2011-10-27T11:40:35Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T11:40:35Z-
dc.conference.date2004en_US
dc.conference.name2004 NACNS Conference, Renaissance in CNS Practice: Transforming Nursing in the 21st Centuryen_US
dc.conference.hostNACNS - National Association of Clinical Nurse Specialistsen_US
dc.conference.locationSan Antonio, Texas, USAen_US
dc.descriptionConference theme: Renaissance in CNS Practice: Transforming Nursing in the 21st Century, held on March 11 to 13, 2004 in San Antonio, Texas, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.en_US
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