Safety First Column:  Reducing SREs, Decreasing Risk for CAUTIS and CLABSIs, Heparin Infusion Therapy
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Safety First Column: Reducing SREs, Decreasing Risk for CAUTIS and CLABSIs, Heparin Infusion Therapy

By: Lindsay Alexander, Patient Safety Manager
D’ Anna Stekli, Infection Prevention and Control Manager
Pratixa Patel, PharmD, Medication Safety Officer

Kettering Health has recommitted to safety with the Safety First program. With this program, Kettering Health is using the five principles of High Reliability Organizations to commit zero harm to our patients. These principles are

  • Preoccupation with Failure (addressing failures immediately and completely)
  • Reluctance to Simplify (understand that problems are complex and may require complex solutions)
  • Sensitivity to Operations (Realizing that issues arise on the front lines, and listening to every voice)
  • Commitment to Resilience (Recover quickly from issues)
  • Deference to Expertise (Trust subject matter experts)

Safety improvements

With the Safety First Program, Kettering Health has partnered with Press Ganey to implement best practice for root cause analysis (RCA) of serious reportable events (SRE). Having a robust RCA process for SREs allows us to ensure we get to the true root cause and implement the right corrective actions to prevent the safety event from reoccurring. 

Some of the changes to the RCA investigation process include:

  • Campus executive sponsorship of the investigation
  • 1:1 interviews with the people involved with the case
  • Involvement of subject matter experts in the case review
  • Standardized process for investigation with multiple points in the process to share learnings with staff
  • Sequencing of events in the case to identify what happened, discuss what should have happened, and understand where the process broke down

The focus of the RCA is on the process and system failures, not on employee blame. We want to learn from the event to help prevent it from happening to another patient in the future.   

This RCA investigation process allows us to align with two of the HRO principles:

  • Preoccupation with Failure
  • Commitment to Resilience

Safety data

A goal of the RCA investigation process is to reduce the number of SREs across Kettering Health. Below is a chart with the rate by month for SREs.

Great Catches:

A “great catch” is when someone does something to proactively prevent harm from reaching the patient. 

Below is a list of great catches across Kettering Health—thank you all for your attention to detail and willingness to speak up for safety. 

  • Pharmacist Jon Czyzewski identified an unusually high dosage of Lantus insulin that was ordered for a patient. Jon discussed with the nurse that the dose ordered was too high and unsafe.  
  • Alayah Keys, a nurse on a MedSurg unit at Soin Medical Center, observed that her patient’s NG and O2 tubing were taped together increasing pressure to the patient’s inner nose causing blanchable redness. Alayah adjusted the tubing and secured it correctly and applied foam pads to the O2 tubing. By the end of the shift the redness was gone, and Alayah prevented a pressure injury for this patient. 
  • Amanda Adkins and Susan Broerman from Southview Medical Center’s Peri-Op department noticed that the physicians H&P did not match the consent. The patient was held in pre-op until clarification could be obtained. 
  • Ashley Gainey at Fort Hamilton Hospital identified a patient with the incorrect name band.  

Infection Control-Tips to protect proned patients from CAUTIs and CLabsis

  • When patients must be proned as part of their treatment for COVID-19 or other conditions, this can pose an increase in risk for CAUTIS and CLABSIs, due to the unique patient position. Here are some tips to help reduce the chances for a central line catheter related infection to develop:
    • Empty the patient’s urinary drainage bag just prior to being proned and before returning the patient back to the normal position.
    • Move the Statlock or other Foley securement device from the inner thigh to the outer thigh to help reduce the chance for a HAPI to develop.
    • If a patient has a central line in the IJ region and it is anticipated that he/she will need to be proned, consult with the attending physician and the PICC nurse to see if a PICC line can be placed to replace the IJ line, as IJ central lines are at risk for contamination from patient oral secretions.
    • If the IJ line can’t be replaced, keep the neck and chest region clean as much as possible.
    • Make sure that the patient gets a CHG bath daily as required, preferably during a portion of the day when the patient is not being proned when it is easier to ensure that the patient is being cleaned thoroughly.

Medication Safety


Heparin infusion therapy utilizes weight-based treatment protocols for indications such as DVT/PE/AFIB or ACS/MI/unstable angina. Ensure the patient weight is recorded in Epic to initiate the heparin infusion protocol. There are two heparin infusion protocols in Epic: DVT/PE/AFIB and ACS/MI/unstable angina.

Did you know there is a maximum infusion dose limit when initiating a new heparin infusion order for the first time?

  • DVT/PE/AFIB:  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
  • ACS/MI/Unstable Angina:  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.

To correctly initiate the heparin infusion with the correct dose, in Epic MAR:

Program dose in Alaris pump:

September 30, 2021