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Lessons Learned/Best Practice Scenarios

Lessons Learned
    Lesson 1    Lesson 3  
    Lesson 2    Lesson 4
    
Best Practice Scenarios
    Case 1

Lessons Learned

These scenarios are presented in the context of the “Perianesthesia Patient Safety Net with Related Event Types.”

 LESSON 1  
 Category:  Safety Net Event XV. V: Physician Order Entry (POE) problem
 Topic:  Error in POE
 Error Type:  Category B - an error that occurred but did not reach the patient

  Situation

  • Provider entered two opioid orders for a PACU patient with unclear instructions. (Fentanyl 50 mcg IV every 5 minutes for pain to maximum of 1,000 mcgs; Dilaudid 0.4 mgs IV every 10 minutes for pain /maximum of 2 mgs) for a PACU patient Nurse selected the appropriate opioid to be given first.

  Background

  • The State Board of Nursing scope of practice for medication administration includes the implementation of a medication as ordered. It does not allow the nurse to choose the appropriate medication from a list of opioid orders.
  • No patient harm was observed.

  Assessment

  • Provider issuing the orders was not aware of the Nursing Scope of Practice and the implications of potential harm to patient.

  Recommendation

  • Perform provider education.
  • Report the event to the Performance Improvement Department to support change in providers’ practice.
  • Information Technology department to add a prompt in the electronic PACU Physician Order Entry system: “Attention Provider (when ordering an opioid) - only one narcotic order at a time.”

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 LESSON 2   
 Category:  Safety Net Event I. A: Patient misidentification
 Topic:  Mislabeling of blood specimen container
 Error Type:  Category B - an error that occurred but did not reach the patient

  Situation

  • A blood specimen collection container was sent to the laboratory accompanied by the correct requisition, but with no identifying patient label on the container.

  Background

  • Specimen labeling policy includes the correct patient, order, container, requisition form and label.
  • Blood specimen had to be re-drawn; no harm to patient.
  • Contributory factors, such as distractions and interruptions have been related to medication errors.

  Assessment

  • A new clinical technician was notably distracted while completing the requisition and specimen labeling. Technician was asked to help admit a patient arriving on the unit in ten minutes while sending the specimen to the laboratory. Technician hurried the process and forgot to place the label on the container.
  • The technician felt stressed and rushed.
  • The charge nurse could have waited to give another assignment until the specimen draw was completed.

  Recommendation

  • Clinical technician: organize all blood draw specimen supplies and labels in one place. Take the time needed to follow every step in the blood draw process.
  • Charge nurse: avoid unnecessary staff member distraction/interruption while he/she is engaged in performing a procedure; be sensitive to the capability of a new staff member engaged in learning to organize his/her work assignments.

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 LESSON 3  
 Category:  Safety Net Event I. A: Patient misidentification
 Safety Net Event II. C: Improve the effectiveness of communication among caregivers
 Topic:  Electronic Documentation on wrong electronic medical record
 Error Type:  Category C - an error that occurred and did reach the patient but did not cause harm

  Situation

  • A PACU staff nurse received report, from the OR nurse, on a patient arriving in PACU. The PACU nurse began clinical documentation in the electronic record.
  • The electronic record was “closed” in preparation for transfer of care, pending transfer to the Phase II unit. At the same time, a billing department clerk noted the absence of appropriate electronic time stamps on the patient record. The clerk’s query led to a discovery that the entire case was documented on the wrong patient.

  Background

  • Medical records require accurate documentation,to include the right patient, right encounter, right provider, and right time.
  • There was no harm to patient related to transfer of care.
  • The incorrect electronic record was reproduced as a paper record for the correct patient.
  • The electronic record, previously assigned to an incorrect patient, was nullified.

  Assessment

  • The perianesthesia electronic documentation system was only recently implemented.
  • The time period when the patient first arrives into Phase I PACU is task laden. It requires attention to detail and vigilance toward the patient, reporting hand-off provider, and clinical assessments.
  • Proper patient identification procedures, not limited to selection of correct electronic record, are critical to safe care.

  Recommendation

  • Re-educate the electronic documentation end users.
  • Establish ongoing audits to monitor documentation standards compliance.

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 LESSON 4  
 Category: Safety Net Event III.D: Improve the safety of using medications 
 Topic:  Adverse event
 Error Type:  Category F - an error that occurred which may have contributed to or resulted in temporary harm to the patient, and required initial or prolonged hospitalization

  Situation

  • Mr. T. arrived in the PACU two hours ago. He is sleeping soundly post spinal anesthesia with IV sedation, and is hard to awaken.

  Background

  • Mr. T. has a history of COPD.
  • He received 50mcg of Fentanyl three hours ago. No complaint of pain or pain medication has been given in the PACU.
  • Temperature = 98.2; Pulse = 72; Respirations = 12; Blood Pressure = 142/74; Oxygen saturation = 99% on O2 at 3 liters/minute.

   Assessment

  • Mr. T. continue to have slow and shallow breathing and condition was not comparable to baseline status.
  • ABG was taken; PaCO2 = 60.
  • Prolonged hospitalization expected.

  Recommendation

  • Obtain pulmonary consultation. Transfer patient to the ICU; place on BiPAP.

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Best Practice Scenarios

  CASE 1

  Topic

  • The assessment of an acute stroke patient cared for in Phase II PACU.

  Problem

  • A 55 year old female outpatient was prepared for discharge. The nurse continued to observe the patient, who was sitting in a chair waiting for a ride home. Suddenly, the patient began to experience left arm weakness accompanied by a curious change in speech patterns.

  Actions

  • Taken The PACU nurse immediately returned the patient to bed and contacted the anesthesia provider.
  • The PACU nurse, who was well informed about the institution’s Stroke Center, independently activated an emergency call to initiate stroke care.
  • The patient underwent immediate diagnostic radiological procedures, and was then transferred to the Neurology Critical Care Unit/Stroke Center.

  Outcome

  • The patient sustained a cerebral bleed with left sided paralysis.

  Best Practice

  • The time period between the nurse's assessment, completion of diagnostic tests and transfer to the Stroke Center was 1.5 hours. This timeline was remarkably efficient. More importantly, the PACU nurse's keen assessment of overt and covert stroke symptoms and the rapid course of action taken prevented further harm to the patient. The PACU nursing staff was later recognized by the institution's safety committee for vigilant monitoring and effective teamwork practices.

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