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March Safety First Column: Great Catches, Medication Safety

Safety

Kettering Health has re-engaged our commitment to safety with the Safety First Program. The Safety First Program at Kettering Health is committed to zero harm for our patients and staff.

We can achieve zero harm with the help of staff using 5 key safety behaviors:

  • Pay attention to detail
  • Communicate clearly
  • Have a questioning attitude
  • Operate as a team
  • Speak up for safety

In review of several root cause analyses (RCA), staff distractions led to an error.  The probability of making an error increases when completing complex tasks, or when dealing with factors like pressure, interruptions, distractions, fatigue, and when completing complex tasks. When completing a task while faced with the above factors, use the STAR technique to help with attention to detail. Examples include reading a label when reviewing an Epic warning, while entering data or documenting, selecting medications, or connecting a patient to oxygen.  

S: Stop and pause for 1-2 seconds. 

T: Think about the act you are about to perform.

A: Act

R: Review your response.

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 2022 Great Catches

  • Thank you, Renee Shiveley, for your great catch. Kcentra was administered to a patient in the Kettering Health Piqua emergency department, then the patient was transferred to Kettering Health Main Campus, where the critical care physician ordered Kcentra to be administered again. Pharmacist Renee Shively remembered this was the same patient that received the Kcentra in Piqua. This is a great catch because the order was auto-verified in the emergency department, but when it was ordered again at Main Campus there was no duplicate warning fired because the patient was registered under a separate encounter. Renee contacted Piqua and validated the administration and discussed it with the ICU physician. The order was dc’d. 
  • Thank you, Grace Hirschler for the February Great Catch of the Month.  Grace completed an EKG on a patient which read normal. The patient’s symptoms were consistent with a myocardial infarction, so Grace completed 2 more EKGs. The third EKG was abnormal and required a cardiac alert. The patient was taken to the cath lab. Thank you, Grace, for going above and beyond for your patients!
  • Special shout-out to Dr. Karabatak for his literal great catch in the Cath Lab.  A bat flew into the staff area and Dr. KaraBATak caught it with a trash can and released it outside.   

Infection Control

To help central line dressings stay in place, Mastisol and Detachol are now in all ICU and step-down units supply rooms. Mastisol is a dressing adhesive and should be used on all IJ central line dressings, sweaty patients, and when placing a new central line dressing on patients who have had a dressing disruption (the dressing did not last for the full seven days). Detachol is a skin adhesive remover that works with Mastisol to gently aid in dressing removal while preserving skin integrity. If Mastisol is used, Detachol should be used when removing the dressing. When using Mastisol to place a central line dressing, write “M” by the central line dressing date to indicate that Mastisol was used for the dressing. This will indicate to other staff members that Detachol needs to be used when removing the dressing.

The updated policy and algorithm regarding when isolation precautions can be removed for patients can be found on the Infection Control Intranet page under the Resources tab at the top.

Medication Safety

Heparin Weight-based Infusions: Heparin Mar Calculators

Heparin weight-based infusions are titratable infusions that are initiated by using patient’s weight and then titrated every six hours based on Anti-Xa lab levels. To ensure the accuracy of following the protocol dosing, it is highly encouraged to use the Initiation and the Dose Adjustment calculators for Heparin infusions.

 Did you know there is a maximum infusion dose limit when initiating a new Heparin Infusion Order for the first time?

  1. DVT/PE/AFIB Protocol:  Initiate infusion at: 18 Units/Kg/Hr with MAXIMUM ADMIN DOSE= 1800 UNITS/HR
  • After 6 hours, review Anti-Xa level and follow titration parameters accordingly

2. ACS/MI/Unstable Angina Protocol:  Initiate infusion at 12 Units/Kg/Hr with MAXIMUM DOSE= 1000 UNITS/HR

  • After 6 hours, review Anti-Xa level and follow titration parameters accordingly

3. The use of the Initiation calculator in the MAR will ensure you DO NOT exceed the Maximum Doses to start a new infusion.

Utilize the initiation calculator in the MAR, when initiating new infusion:

Six hours later: Anti-xa level results. Use adjustment calculator in Epic MAR.

Anti-Xa level result is entered.

April 1, 2022