Kettering Health has five safety behaviors designed to keep our patients safe. They include
- Communicate clearly
- Operate as a team
- Pay attention to detail
- Speak up for safety
- Have a questioning attitude
In September the system saw a spike in serious reportable events (SRE). A root cause analysis (RCA) was completed on the cases. While the 17 SREs were different, there were common themes identified. One was breakdown in communication.
A large amount of communication is done verbally, which increases risks for errors. To avoid those potential errors, use universal skills for communication and speak clearly with intent.
Tools to use:
- Read and repeat back: “You stated to take Mrs. Smith’s blood sugar in 10 minutes. Is that correct?”
- Ask clarifying questions: “Doctor, when would you like me to administer Mrs. Smith’s breathing treatment?”
- SBAR (Situation, background, assessment, recommendation): “Mrs. Smith has an altered mental status and attempts to independently get out of bed. Mrs. Smith fell at home three days ago. Her fall score is 100. I recommend we place her on a bed alarm.”
Great Catches
A great catch is when someone proactively prevents harm from reaching a patient. Kettering Health uses safety events reported through Great Catches and SAFE events to make positive changes and improvements across the system.
Great Catches are celebrated each day during campus Daily Safety Briefings. Please share your Great Catches with your leader, so your commitment to patient safety can be celebrated.
September 2022 Great Catches
- Thank you, Chantelle Brown from MS5 at Soin Medical Center, for your Great Catch. Chantelle noticed that a patient was not placed on telemetry as ordered. Chantelle saw the order and immediately put patient on the heart monitor. The patient was bradycardic into the 30s and 40s, and the physician was made aware. Thank you, Chantelle, for paying attention to detail.
- Thank you, Frank Hoffman from the Pharmacy at Kettering Health Washington Township. Frank noted the pharmacy labels for diclofenac 1% topical gel was labeled “chemotherapy agent” with a PPE warning. This was reported to the medication safety officer and hazardous drug technician to correct labeling. Than you, Frank, for speaking up for safety.
- Thank you, Madalyn Reichert from the PACU at Soin. This patient had a citrus allergy. The orange and red lozenges contain citrus derivatives, and the medication was not flagged as an allergy when scanned to be given. The error was caught, and the medication was not given. Thank you for paying attention to detail.
Medication Safety
It should come as no surprise that human-related factors are the number one element influencing medication errors. Whether it’s distractions, workload, knowledge deficits, or any other of an innumerable list of reasons, everyone make mistakes. Some of these mistakes are relatively harmless, like wearing two different shoes for a day. Others can be serious, or even fatal, such as those involving high-risk medications.
Given that people make mistakes, and that errors involving high-risk medications are potentially very dangerous, we have implemented several safeguards to help minimize the risk of such errors. Where possible, we have 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 have implemented a system of double checks. Medications that include a double-check requirement are usually high-risk medications such as chemotherapy, insulin, heparin, and doses for newborns.
A double check requires two people to look at a given dose to assess all aspects of the six “rights.” This includes the right drug, right patient, right dose, right route, right time/frequency, and right reason. This should be done with minimal influence from the first party regarding what is being double checked. These double checks have been shown to improve the accuracy of medication administrations, since two people are not likely to make the same mistake back-to-back.
Test yourself!
- Nurse Joe calls overhead, “I need someone for an insulin double check in room 12.” nurse Bobby comes to the room, where Joe says, “I have 12 units of Humalog here for Mrs. Price, but I threw away the vial.”
- Nurse Sam asks her coworker to come to room 14 for a double check. None of her fellow nurses are available, so Sam asks a nearby pharmacist for assistance. The pharmacist comes to the room and checks the six rights before signing off the dose.
- A nurse in the NICU asks nurse Jean, “Can you make sure these amoxicillin NICU doses are 55mg for Baby A and 45mg for Baby B?” Jean makes sure that the syringes contain the correct volume, and then signs off the doses.
- Nurse Alice comes to the room at the request of nurse Jan. Together they look at the heparin drip Jan set up to run. Alice reads the fields on the pump, while Jan verbally confirms the values from memory.
- Tom, an infusion nurse, comes to the nurse’s station and asks someone to double check his medication in room 8. Ruth, his fellow nurse, joins him in the room and checks the medication information against the order in Epic while Tom waits nearby to answer any questions.
Check your answers below:
- Not a true double check
- Correct! This is a true double check.
- Not a true double check
- Not a true double check
- Correct! This is a true double check.