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April Safety First Column: Great Catches, Medication Safety

Safety

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

To achieve zero harm, it is imperative that we learn and improve after a safety event to prevent the event from reoccurring. Staff need to feel safe raising workplace safety concerns and report safety mistakes without fear of punishment.

Kettering Health uses safety events reported through Great Catches and Midas to make positive changes and improvements. One example is oxygen events. 

Oxygen Updates

Through Midas event review it was identified that there was an increase in oxygen events at the end of 2020 and early 2021.

In 2021 action was taken to improve oxygen safety. Changes included

  • Creation of the oxygen ticket to ride (TTR). The TTR is a two-person checklist to ensure patients on oxygen are connected correctly. The ticket to ride has been revised and improved to reflect staff recommendations. 
  • Standard room configuration for oxygen and air flow meters and universal adapters
  • New oxygen tanks implemented that show how much oxygen is left in the tank based on time. The tanks alarm when they are at a ¼ tank or have less than 15 minutes left of oxygen.    

Since the end of January 2022, the new tanks have been implemented at Miamisburg, Main Campus, Soin, Greene, and Washington Township.

From February-April 2022 there has only been one oxygen event across the system.     

Thank you for reporting and sharing oxygen events in Midas so we can learn, improve, and prevent future patient safety events.    

Bed Alarms

When a serious reportable event (SRE) fall occurs, a Root Cause Analysis (RCA) is conducted.  Recent RCA’s revealed that staff thought the bed alarm was set when it wasn’t. Stryker beds show a green light when iBed Awareness is set. Some staff assume that the green light means the bed alarm is activated, though it may not be.     

To set the bed alarm follow the steps listed below.

Stryker will be at each campus in the month of April/May and July/August making rounds on units to provide one on one education.

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.

March 2022 Great Catches: 

  • Thank you, Gabby Feldmeyer (Miamisburg), for catching an incorrect dose of IV Heparin before it was administered to the patient.
  • Thank you, Tiffany Hargrave (Washington Township) for noticing the wrong patient was taken to MRI and calling radiology to let them know.
  • Thank you, Stacy Wilson (Troy). A patient was admitted with subtherapeutic INR. At discharge Stacy noticed the patient’s prescription for Coumadin would be delayed and the patient would go two days without medication. Stacy contacted the physician and the patient was given medication prior to discharge.

Medication Safety

Kettering Health is committed to providing safe care to our patients by engaging and supporting our healthcare professionals who are responsible to deliver safe care. To ensure our commitment, we continuously review our current systems to update and enhance safety processes.

Historically, medications can be searched in Omnicells by only typing in one (1) character. It was identified that this can lead to an increased chance in selecting the wrong medications, leading to medication errors. An example of this is where a nurse intending to remove Versed and typed in “VE” and saw “Vecuronium” appear first in the medication list and removed it.  She did not realize it was not Versed (midazolam). This unintentional error had severe consequences and significant harm. Even though it occurred at a different institution, it could have happened anywhere.

System Update

To align with best practices to keep our patients safe, effective April 18, 2022: 

  • Medication search in Omnicell will require a minimum of three (3) characters. If you attempt to search by typing in 1-2 characters of the medication, Omnicell will not be able to search for medications.

This safe system enhancement is supported by Nursing, Pharmacy, and Patient Safety.

May 4, 2022