2.50
Hdl Handle:
http://hdl.handle.net/10755/344146
Category:
Abstract
Type:
Poster
Title:
Improving Heparin Safeguards: Correcting the Failed Double Check Process
Author(s):
Robin, Nancy; Brennan, Denise; Kane, Joanne
Lead Author STTI Affiliation:
Non-member
Author Details:
Nancy Robin, M.Ed., RN, CEN, nrobin@lifespan.org; Denise Brennan, MSN, RN, CNL; Joanne Kane, AD, RN, CEN
Abstract:
Evidence-based Practice Abstract Purpose: Double check of high alert medications is a strategy that is used to help detect errors before reaching the patient. Double checks were completed but heparin administration errors were still occurring. One error is one too many. The objective was to decrease heparin administration errors in the Emergency Department (ED). Design: Patient safety/Quality Improvement project. Setting: Teaching 60,000 visits, urban community hospital. Participants/Subjects: All ED RN’s, ED Nurse Educator, Quality MD, ED Director, ED Safety Officer. Methods: One strategy alone will not prevent errors from occurring. Barcode scanning or ED based pharmacists are strategies used at other facilities to prevent errors from reaching the patient. The ED nurse is responsible for medication safety ensuring that the “Five Rights” are adhered to. Over the past three years, there had been an increase in heparin infusion errors. The ED occurrence rate for heparin errors per 1000 heparin infusion orders was 7.6 in 2011 and 5.8 in 2012. In the first 6 months of 2013, the error rate had jumped to 19.7 per 1000 heparin infusion orders. This upward trend was extremely concerning. ED nurses act as the second verifier to make sure the heparin order is correct. There is a heparin calculator in the electronic record which is easily accessible for reference. When humans are involved, there is always the chance for error. Numerous studies have demonstrated the ability of independent double checks to detect errors. Nurses reported that the double checks were being performed. Nurses revealed that heparin double checks were often rushed. The importance of blood transfusion verification was reported to have more value. Although this was anecdotal reporting, it prompted further investigation into the practices of nurses performing the double check on heparin. The ED educator met 1:1 with all RN staff to verify competency when performing a double check of heparin administration. Eighty nurses were observed. The educator acted as the primary nurse in setting up the Heparin infusion and reviewing the order. An actual order was acted upon with embedded errors. Only 5 nurses performed the double check independently and found the errors. Seventy five nurses thought they were performing a double check correctly. Results/Outcomes: In a review of the most recent heparin errors, an ineffective double check process was discovered. Nurses had lost sight of the importance in performing the double check independently. Through further competency verification, nurses now are aware of a checklist (5 items) that independently needed to be completed. It is more than raising awareness. Competency verification is needed. The error rate per 1000 heparin infusion orders was 19.7 in the 6 months prior to competency verification. There has been one error based on an incorrect weight since the project began in July 2013, dropping the error rate to 3.9. Data continues to be collected. Implications: The 2014 National Safety Goal 03.05.01 wants to reduce the likelihood of patient harm from anticoagulant therapy. To minimize risk, it is important to improve safeguards which include verifying that independent double checks are completed independently.
Keywords:
Double checks; High alert medications; Heparin safeguards
Repository Posting Date:
4-Feb-2015
Date of Publication:
4-Feb-2015
Conference Date:
2014
Conference Name:
2014 ENA Annual Conference
Conference Host:
Emergency Nurses Association
Conference Location:
Indianapolis, Indiana, U.S.A.
Description:
2014 ENA Annual Conference Theme: Safe Practice, Safe Care. Held at the Indiana Convention Center
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.language.isoen_USen_GB
dc.type.categoryAbstracten_GB
dc.typePosteren_GB
dc.titleImproving Heparin Safeguards: Correcting the Failed Double Check Processen_GB
dc.contributor.authorRobin, Nancyen_GB
dc.contributor.authorBrennan, Deniseen_GB
dc.contributor.authorKane, Joanneen_GB
dc.contributor.departmentNon-memberen_GB
dc.author.detailsNancy Robin, M.Ed., RN, CEN, nrobin@lifespan.org; Denise Brennan, MSN, RN, CNL; Joanne Kane, AD, RN, CENen_GB
dc.identifier.urihttp://hdl.handle.net/10755/344146-
dc.description.abstractEvidence-based Practice Abstract Purpose: Double check of high alert medications is a strategy that is used to help detect errors before reaching the patient. Double checks were completed but heparin administration errors were still occurring. One error is one too many. The objective was to decrease heparin administration errors in the Emergency Department (ED). Design: Patient safety/Quality Improvement project. Setting: Teaching 60,000 visits, urban community hospital. Participants/Subjects: All ED RN’s, ED Nurse Educator, Quality MD, ED Director, ED Safety Officer. Methods: One strategy alone will not prevent errors from occurring. Barcode scanning or ED based pharmacists are strategies used at other facilities to prevent errors from reaching the patient. The ED nurse is responsible for medication safety ensuring that the “Five Rights” are adhered to. Over the past three years, there had been an increase in heparin infusion errors. The ED occurrence rate for heparin errors per 1000 heparin infusion orders was 7.6 in 2011 and 5.8 in 2012. In the first 6 months of 2013, the error rate had jumped to 19.7 per 1000 heparin infusion orders. This upward trend was extremely concerning. ED nurses act as the second verifier to make sure the heparin order is correct. There is a heparin calculator in the electronic record which is easily accessible for reference. When humans are involved, there is always the chance for error. Numerous studies have demonstrated the ability of independent double checks to detect errors. Nurses reported that the double checks were being performed. Nurses revealed that heparin double checks were often rushed. The importance of blood transfusion verification was reported to have more value. Although this was anecdotal reporting, it prompted further investigation into the practices of nurses performing the double check on heparin. The ED educator met 1:1 with all RN staff to verify competency when performing a double check of heparin administration. Eighty nurses were observed. The educator acted as the primary nurse in setting up the Heparin infusion and reviewing the order. An actual order was acted upon with embedded errors. Only 5 nurses performed the double check independently and found the errors. Seventy five nurses thought they were performing a double check correctly. Results/Outcomes: In a review of the most recent heparin errors, an ineffective double check process was discovered. Nurses had lost sight of the importance in performing the double check independently. Through further competency verification, nurses now are aware of a checklist (5 items) that independently needed to be completed. It is more than raising awareness. Competency verification is needed. The error rate per 1000 heparin infusion orders was 19.7 in the 6 months prior to competency verification. There has been one error based on an incorrect weight since the project began in July 2013, dropping the error rate to 3.9. Data continues to be collected. Implications: The 2014 National Safety Goal 03.05.01 wants to reduce the likelihood of patient harm from anticoagulant therapy. To minimize risk, it is important to improve safeguards which include verifying that independent double checks are completed independently.en_GB
dc.subjectDouble checksen_GB
dc.subjectHigh alert medicationsen_GB
dc.subjectHeparin safeguardsen_GB
dc.date.available2015-02-04T11:27:18Z-
dc.date.issued2015-02-04-
dc.date.accessioned2015-02-04T11:27:18Z-
dc.conference.date2014en_GB
dc.conference.name2014 ENA Annual Conferenceen_GB
dc.conference.hostEmergency Nurses Associationen_GB
dc.conference.locationIndianapolis, Indiana, U.S.A.en_GB
dc.description2014 ENA Annual Conference Theme: Safe Practice, Safe Care. Held at the Indiana Convention Centeren_GB
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_GB
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