Cynthia Turner Medication Safety Pharmacist

Session E3

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

No affiliation with a commercial organization

Decrease omitted warfarin doses by 50% within 6 months, starting with 7 North Surgical Unit at the 500 bed Royal Jubilee Hospital

Started as a Project ◦ Mandate - within scope of job

◦ 6 month timeline

Accreditation ROP – High Alert Meds

(PSLS)

◦ Top 10 reported meds

Up to 23 Sept 2014

0

200

400

600

800

1000

1200

RJH & NRGH hospitals

with most errors

RJH 7N

Unit with 2nd highest

reported errors

Omitted

dose

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

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

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

Actions – added INR reminder to: ◦ Patient Care Plan

◦ Nursing Summary Sheet for Patients

◦ MAR: “Review most current INR by 1200h”

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1

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6

Should there be an IDC? Do you currently do an IDC?

Yes

No

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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1

2

3

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5

6

1600h - present 1400h 1700h 1700h if IDC reqd.

Advantages

Disadvantages

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

Anticoagulant Record ◦ No point - imminent Electronic Health Record (EHR)

Warfarin induction protocol ◦ inspired others to lead this charge

Second retrospective 7N chart review

assess whether a 50% improvement in omitted warfarin doses has occurred

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

Contact info Cynthia Turner cynthia.turner@viha.ca