high alert medication quality improvement project for warfarin
TRANSCRIPT
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Cynthia Turner Medication Safety Pharmacist
Session E3
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Cynthia Turner – Team Lead
Rachel Wilson – 7N CNL
Francesca Gill – 7N part time CNL
Lindsay Wheelock – 7N CNE
Rebekah Curran – 7N Pharmacist
Kathleen Mayoh - Lab Leader
Alice Gelpke – Executive Leader
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No affiliation with a commercial organization
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Decrease omitted warfarin doses by 50% within 6 months, starting with 7 North Surgical Unit at the 500 bed Royal Jubilee Hospital
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Started as a Project ◦ Mandate - within scope of job
◦ 6 month timeline
Accreditation ROP – High Alert Meds
(PSLS)
◦ Top 10 reported meds
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Up to 23 Sept 2014
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200
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1200
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RJH & NRGH hospitals
with most errors
RJH 7N
Unit with 2nd highest
reported errors
Omitted
dose
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OMITTED DOSE
= patient Rx warfarin but did not receive the dose
Effect of warfarin measured using INR ◦ Therapeutic INR range = prevents clotting
◦ INR too high = risk of bleeding
◦ INR too low = risk of clotting
◦ Future doses based on INR value
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Retrospective Chart Review (191 doses) ◦ PSLS reports validated
◦ 5% of warfarin doses omitted
*Omitted dose defined as dose not signed for on either cMAR or Anticoagulant Record
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Staff Survey 7 North (12) ◦ Nurses, Unit Clerks, Pharmacist
Vetted improvement ideas ◦ Local 7N Nurse Leader (CNL) & Nurse Educator (CNE)
◦ Island-wide CNL/CNE groups
◦ Anticoagulation Clinic Pharmacists
◦ Lab Leaders
◦ IHealth Informatics specialists
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Actions – added INR reminder to: ◦ Patient Care Plan
◦ Nursing Summary Sheet for Patients
◦ MAR: “Review most current INR by 1200h”
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Should there be an IDC? Do you currently do an IDC?
Yes
No
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Added IDC requirement to Policy:
Added reminder to MAR that “IDC required”
Now stored on unit in labelled bin
Added space for second signature to Anticoagulant Record
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1600h - present 1400h 1700h 1700h if IDC reqd.
Advantages
Disadvantages
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Present dosing time 1600h ◦ More disadvantages than advantages
Other dosing times 1400h ◦ Only works for surgical floor (vitals checked q8h)
1700h with IDC ◦ Main advantage - other IDC meds given at this time
No IDC With IDC
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Anticoagulant Record ◦ No point - imminent Electronic Health Record (EHR)
Warfarin induction protocol ◦ inspired others to lead this charge
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Second retrospective 7N chart review
assess whether a 50% improvement in omitted warfarin doses has occurred
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1. QI project is not a Research project
2. Do not rush the planning phase start with most engaged unit
3. Do not take on bigger projects (out of scope)
4. Be mindful of future state – EHR/CPOE
5. Use knowledge & traction