Raising the Bar On Infusion Safety: A Patient Safety Program

at Baylor Scott & White Health

Improving Infusion Pump Safety: A Systematic Approach

July 18, 2016

AAMI FoundationVision: To drive the safe adoption and safe use of healthcare technology• National Coalition for Infusion Therapy Safety• National Coalition to Promote Continuous

Monitoring of Patients on Opioids• NEW Compendium: Opioid Safety & Patient Monitoring

• National Coalition for Alarm Management Safety• NEW Compendium: AAMI Foundation Management of

Clinical Alarm

Please Consider Making a Donation!Contact Marilyn Flack at mflack@aami.org

A Special Thanks

Thank You to Our PremiereIndustry Partners

Without the generous support of our industry partners, we would not be able to produce the many tools and deliverables created by the coalition to help you improve infusion therapy safety.

The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content.

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Nursing Continuing Education Disclosure Statement• This seminar is jointly provided today with our co-provider, the National Association of

Clinical Nurse Specialists (NACNS).

• 1.0 contact hour will be awarded for this seminar. This seminar may be accessed online at the AAMI Foundation website for nursing CE up to two years from today’s date.

• This continuing nursing education activity was approved by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation (ANCC).

• Criteria for successful completion includes attendance at the session and submission of a completed evaluation form. You can submit the fee for the CE credit by going to the AAMI store at (link will be sent in follow-up email). A link to the evaluation form will be sent to you for completion and a certificate sent to you upon completion of the evaluation.

• The planning committee members have declared no conflict of interest along with our faculty for today’s session.

• Contributions to the AAMI Foundation have been received from the identified sponsors to support program initiatives and projects. However, the program content for today’s seminar has been planned independently by AAMI staff with the seminar presenters.

• Approval of the continuing education activity does not imply endorsement by the provider, ANCC or the Alabama State Nurses Association.

Polling Questions

Speaker Introductions

• Molly A. Hicks, RN, MSN Director of Patient Safety, Baylor Scott & White Health

• Jason Trahan, PharmD Pharmacy Director – Medication Safety, Baylor Scott & White Health

Improving Infusion Pump Safety: A Systematic Approach

July 18, 2016

Disclosures

• None

Presentation Outline• Background• Compliance• Library Optimization

• Alerts • Overrides

• Edits• Good Catches• Alert Effectiveness

• Library Content• Sustainment • Lessons Learned9/25/2013 11

Baylor Scott & White Health More than 900 patient care sites including 48 hospitals

5.1 million patient encounters annually

More than 40,000 employees

More than 6,000 affiliated physicians

Scott & White Health Plan

$9.7 billion in total assets

$7.5 billion in total operating revenue

12

Project Background• Between December 2005 – February 2013 BSWH

launched over 4,000 “smart” pumps in 12 facilities• November 2012 Executive report from vendor

indicated very low compliance with the dose error reduction systems (DERS) and high number of over ride alerts

• Historical data for implementation, training, policy, and quality data was limited

• No systematic approach for assessing metrics or communicating the benefit of DERS system

Strategies to Address

• Interdisciplinary team formed and charged with the following:• Improve Utilization of the Pump Library• Increase patient safety (Program Edits = Good

Catches)• Decrease the number of Alert Overrides (Alert

Fatigue)

9/25/2013 15

Project TeamProject Team

4

ROLE TITLE

Executive Sponsor VP of Patient Safety / CPSO

Co-Team Leads Director, Patient SafetyPharmacy Director- Medication Safety

Team Members Director of Human Factors

Clinical Technology Team Lead

VP Nursing OperationsVP Nursing WorkforceVP of Professional DevelopmentDirector of Clinical Nursing ExcellenceVendor – Clinical Nurse ConsultantVendor – Pharmacy Consultant

Ad-Hoc members Staff nurses / managers for specialty councils

Human Factors Identified Barriers to Compliance

• Programming errors • data entry & calculation

• Usability of the pumps• Takes too long to program• Not familiar with key steps in using the pumps

• Usability of the drug library• Commonly used drugs not easily located• Items not descriptive / intuitive• Common doses not included in library• Too many alerts

• Organization support• No clear expectation about using the drug library• No organized ways to learn

Process Modeling – Fishbone Diagram

Lack of Drug Library Optimization Resulted In:

• High numbers of over rides and alerts and alert fatigue• 22.3% overall rate of ALERTS / 100 programs• 21.3% overall rate of OVER RIDES / 100 programs• 60% of all alerts were from ten ISMP drugs

• Low number of drugs with hard limits• Only 23% of the drugs had hard upper limits (HUL)• Only 0.2 % of the drugs had hard lower limits (LUL)

• No scheduled library updates or owner• No on-going formal process to access drugs

Rapid Cycle Methodology Overview

•Monthly reports•Share results w/ leaders and users

•Review feedback from users emails

•System goals set and shared•Champions identified •Spread “Good Catches” •Facilities developed improvement teams

•Reviewing a set of drugs•Schedule drug library updates•Remove non-formulary drugs•Remove unused library CCA•System-wide retraining•Creating generic antibiotic selections

•Identify opportunities for improvement

•Identify barriers to use•Identify best practices•Target ISMP High Risk drugs 1st

Plan – vendor report was source of problem

identification

Do – several rapid cycle changes

Check -Act – after

reviewing the results

Sharing and Spreading• Communicate Results and Findings:

• To leadership, CNO’s, managers, nursing councils• Enhance communication to pharmacy leaders• Post results in central location on system intranet site• Discuss at specialty councils: Patient Safety Officers,

Risk Managers, Professional Development, Critical Care

• Share at Safety and Best Care meetings• Metrics added to the monthly dashboard report• Set up email address for users to provide feedback• On going dialogue with vendor to benchmark with

other national users

SAMPLE REPORTS

Infuser Drug Library Install Status Report

SITE PUMPCHANNELS

LIBRARY INSTALLED

% INSTALLED

Facility A 726 647 89%Facility B 161 134 83%Facility C 1550 1318 85%Facility D 320 286 89%Facility E 385 352 91%Facility F 660 603 91%Facility G 378 358 95%Facility H 255 239 94%Facility I 72 55 76%

Monthly Compliance Report by Facility by CCA*

*Clinical Care Area=CCA

Facility A B C D E F G H I J K L TOTALS

GOOD CATCH REPORT

“Good Catch” Report• Good catches or saves: Potential programming errors avoided by

using the drug library. • Human factors: Being more careful is NOT sufficient. # of errors

prevented from reaching patients in April 2016 for selected drugs:

26

FacilityMedication A B C D E F G H I J K L TotalDexmedetomidine 7 1 19 48 1 11 6 6 4 105 4 4 216Insulin 3 3 3 65 6 1 8 4 22 5 120Heparin 2 4 31 11 2 10 3 3 1 1 12 80Amiodarone Rapid LD 1 1 38 11 3 18 1 73Nicardipine 20 mg/200ml 1 2 18 2 3 5 2 4 24 61Diltiazem 2 11 1 6 8 5 16 1 1 51Fentanyl 12 2 4 30 1 1 1 51Norepinephrine Max Con 6 2 3 23 5 5 1 45Amiodarone 1.8 mg/ml 2 15 2 9 2 9 3 1 43Potassium Phosphate 5 3 18 1 9 1 4 41Norepinephrine STND 2 5 6 7 8 2 2 5 37Nicardipine 40mg/200 ml 5 1 1 12 1 13 1 2 1 37

Graph of Library Utilization

9/25/2013 27

30.0%

35.0%

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Jan-

13Fe

b-13

Mar

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13Ju

l-13

Aug

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b-14

Mar

-14

Apr

-14

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Aug

-14

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-14

Oct

-14

Nov

-14

Dec

-14

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b-15

Mar

-15

Apr

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Aug

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Library Optimization

• Overrides - Alert Fatigue.• Edits - “Good Catches”• Initial Process to address - Alignment

• Review of Standard Order Sets• EHR Review

• Limit Evaluation• Data Use; Evidence Based Medicine

9/25/2013 28

Alerts

• Process Developed• Identify top 10 override alerts per quarter• Review EHR Order Sets• Review Organizations standard medication reference• Adjust limits based on data

9/25/2013 29

Rate of ALERTS per Programs

9/25/2013 30

7.60%

2.16%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

1 QTR -13

2 QTR -13

3 QTR -13

4 QTR -13

1 QTR -14

2 QTR -14

3 QTR -14

4 QTR -14

1 QTR -15

2 QTR -15

3 QTR -15

4 QTR -15

1 QTR -16

Alerts Programs1 QTR ‐ 13 52369 6889922 QTR ‐ 13 55554 8729033 QTR ‐13 49152 8598584 QTR ‐ 13 47943 9248831 QTR ‐ 14 48015 9762252 QTR ‐ 14 42984 9701863 QTR ‐14 31071 9057034 QTR ‐ 14 31934 9847931 QTR ‐ 15 29607 9896542 QTR ‐ 15 27815 9609503 QTR ‐15 29538 10635264 QTR ‐ 15 29145 12433711 QTR ‐ 16 29215 1352590

TAKE HOME:Avoided 73,582 nuisance alerts in first QTR 2016 from baseline

Rate of EDITS per Programs

9/25/2013 31

TAKE HOME:Additional 4,176 errors avoided in first QTR 2016 from baseline

0.47%

0.78%

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

0.80%

0.90%

1 QTR -13

2 QTR -13

3 QTR -13

4 QTR -13

1 QTR -14

2 QTR -14

3 QTR -14

4 QTR -14

1 QTR -15

2 QTR -15

3 QTR -15

4 QTR -15

1 QTR -16

Edits Programs1 QTR ‐ 13 3259 6889922 QTR ‐ 13 4580 8729033 QTR ‐13 5448 8598584 QTR ‐ 13 5894 9248831 QTR ‐ 14 6324 9762252 QTR ‐ 14 6511 9701863 QTR ‐14 6292 9057034 QTR ‐ 14 7204 9847931 QTR ‐ 15 7420 9896542 QTR ‐ 15 7357 9609503 QTR ‐15 8090 10635264 QTR ‐ 15 9570 12433711 QTR ‐ 16 10533 1352590

Alert Effectiveness

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

1 QTR- 13

2 QTR- 13

3 QTR-13

4 QTR- 13

1 QTR- 14

2 QTR- 14

3 QTR-14

4 QTR- 14

1 QTR- 15

2 QTR- 15

3 QTR-15

4 QTR- 15

1 QTR- 16

9/25/2013 32

Edits Alerts1 QTR ‐ 13 3259 52369

2 QTR ‐ 13 4580 55554

3 QTR ‐13 5448 49152

4 QTR ‐ 13 5894 479431 QTR ‐ 14 6324 48015

2 QTR ‐ 14 6511 42984

3 QTR ‐14 6292 310714 QTR ‐ 14 7204 31934

1 QTR ‐ 15 7420 29607

2 QTR ‐ 15 7357 27815

3 QTR ‐15 8090 295384 QTR ‐ 15 9570 29145

1 QTR ‐ 16 10533 29215

TAKE HOME:Baseline 1 edit to every 17 Alerts

Last QTR 1 edit to every 2.8 Alerts

Pump Library Contents• Shared e-mail account created for direct feedback• Established processes for:

• Set updates quarterly aligned with EHR updates• Adding new medications as approved by Pharmacy and

Therapeutics Committee• Surveys and Meetings with frontline nurses• Standardization of Concentrations/Preparations• Identifying specialty councils for pump library

“ownership”• Change in order of appearance for high use

medications.

Compliance is up and alert overrides are going down …but are we safer?

17.1

2.7

0

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0.0%

20.0%

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Journey of Infusion Safety - BSWH/NTXCompliance increased by 129% and alerts 528% more effective

Resulting in 217% more errors were avoided# of Errors AvoidedCompliance to Drug Library UseAlerts effectiveness (# of alerts per avoided error)

Sustainment

Hardwiring the improvement : • Include Pump training with focus on “why” during orientation, • Provide eLearning option, “just in time” review • Shift Huddles / rounding, • Ongoing sharing of data with leaders, users, and committees• Performance goals by CCA (i.e. Critical care, ED, etc.)• Super user huddles started• Created short demo videos• Sharing good catch reports to front line staff

Process Owners:• Being defined by role / facility and assigning

• Receiving update to the pump• CCA drug list• Drug limits • Running reports• Orientation

Sustainment

16

Next Steps \ Lessons Learned

Next PDCA Cycle:Identify the most frequently used drugs by CCAOptimize pump screens so “top 10 drugs” are on the first screenTrain facility person to run Med Net DataDevelop ‘can’ report to provide facilities routinely / automatic Reduce number of nuisance alarms

Lessons Learned Through the Improvement Process:Communication for keeping users informed “real time” of compliance.Present data in a simple fashionIdentify best practices among facilities and share Unintended consequences with software updatesUnintended consequences of drug library optimizationOngoing support for facility teams to problem solve and maintain high compliance and engagement

Next Steps / Lessons Learned

18

ADDITIONAL RESOURCES

9/25/2013 38

9/25/2013 39

Thank you for attending!

Slides & Recording Available Here

Future/Ongoing Initiatives

9/25/2013 41

CE Credit

• See Follow-Up Email!

9/25/2013 42

Mark Your Calendars!

August 8, 2016; 12pm to 1pm

Another in our series: Raising the Bar on Infusion Therapy Safety –Patient Safety Initiatives at Western Maryland Health System and Cameron Memorial Community Hospital

https://attendee.gotowebinar.com/register/6578724789653528580CE credit of 1 hour has been approved for this seminar

Complimentary Resources Safety Innovations Series Alarms Management Patient

Safety Seminars • Seminar Recordings• Webinar Slides• Key Points Checklists

NEW Opioid Safety & Patient Monitoring

NEW AAMI FoundationAlarm Compendium

Thank You to Our PremiereIndustry Partners

Without the generous support of our industry partners, we would not be able to produce the many tools and deliverables created by the coalition to help you improve infusion therapy safety.

The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content.

PlatinumDiamond Gold

Questions?• Post a question on AAMI

Foundation’s LinkedIn

• Type your question in the “Question” box on your webinar dashboard

• Or you can email your question to: mflack@aami.org.

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