Kettering Health reengaged its dedication to safety with the Safety First Program, committing to zero harm for our patients and staff. Kettering Health can achieve zero harm with the help of staff using five key safety behaviors:
- Pay attention to detail
- Communicate clearly
- Have a questioning attitude
- Operate as a team
- Speak up for safety
In a review of several root cause analyses (RCA), it was identified that staff distractions lead to an error. The probability of making an error increases with factors such as time pressure, interruptions, distractions, fatigue, and when completing complex tasks. When completing a task while faced with those factors, use the STAR technique:
S: Stop pause for 1-2 seconds.
T: Think about the act you are about to perform
A: Act perform act
R: Review check for your response.
This technique can help improve attention to detail when doing things like reading a label, reviewing an Epic warning, entering data or documenting, selecting medications, or connecting a patient to oxygen.
According to the University of Michigan, “taking a pause to self-check reduces the probability of an error by a factor of 10 (10x) for a 1 second pause and between 100-1000 for a 2-5 second pause.”
Great catches
A “great catch” is when someone proactively prevents harm from reaching the patient. Great catches are celebrated each day at the respective campus Daily Safety Briefing. Each month Kettering Health selects a Great Catch of the Month, with a yearly winner selected and celebrated at the annual Quality Banquet.
Please share your great catches with your leader so your commitment to patient safety can be celebrated.
February 2023 Great Catch
Thank you, Amanda, from Kettering Health Preble’s Emergency Department, for having a questioning attitude and speaking up for safety. Amanda noticed that Vancomycin 750mg in 250ml does not create a stop time action in the MAR. We appreciate her bringing this forward so a system fix could be developed, preventing possible patient harm system wide.
Medication safety: Dual verification for high-alert medications
High-alert (high-risk) medications have a heightened risk of causing significant patient harm when they are used in error. At Kettering Health, we implemented several safeguards to help minimize the risk of such errors. Where possible, we added automated checks that have an error rate far below what humans can ever achieve on their own. Where automation isn’t possible and the risk of a serious error is high, we implemented a system of dual verifications within the Pharmacy Department as well as upon administration at the bedside. The medications that require a dual verification are high-alert medications such as:
- Chemotherapy
- Insulin
- Heparin
- Medications for newborns/neonates
A dual verification requires two people to look at the medication order and the medication dose to assess all aspects of the six rights:
- Right patient
- Right drug
- Right dose
- Right route
- Right time/frequency
- Right indication
Those “rights” should be independently verified and validated by the second nurse prior to administration of the high-alert medications. There should be minimal influence from the first nurse regarding what is being dual verified. These dual verifications have been shown to improve the accuracy of medication dispensations and administrations, since two people are not likely to make the same mistake back-to-back.