Safety First Column: Serious Reportable Events, Dependent Loops, Heparin
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Safety First Column: Serious Reportable Events, Dependent Loops, Heparin

Safety Learnings

As units across Kettering Health work through potentially network-wide opportunities, it is important that these are shared, so we can continue to grow our culture of safety and be our best for our patients.

Recently, The National Quality Forum has created a list of Serious Reportable Events (SRE) or “never events.” When an SRE occurs, we must complete a Root Cause Analysis (RCA) to determine the root cause(s) of the event and come up with solutions to prevent the event from reoccurrence. Below is an excellent example of an SRE, RCA, and the solutions implemented by the clinical teams in our emergency departments.

Situation In one of our emergency departments (EDs), there was a Behavioral Health patient who was awaiting admission. The patient was restrained but after many hours, the restraints were removed because the patient was stable and calm. The patient approached the nurse’s station with a question and quickly pushed through the breakaway doors and was able to leave the premises. 
Background Appropriate processes were timely and effectively initiated.Assessments and evaluations occurred promptly.While initially restrained, restraints were removed when the patient was calm and stable.Staffing was adequate.Security responded promptly. 
Assessment Systematic error: There needs to be a secure door in place.
Recommendation Breakaway door will be removed and replaced with steel door that is locked. Door will have safety window in place. Temporary fix in place—lock reversal so that door is permanently locked and unable to be utilized as breakaway door.  Conduct a network-wide assessment to ensure breakaway doors are not being used in the EDs to secure the Behavioral Health area.

Great Catches

A “great catch” is when someone proactively prevents harm from reaching the patient. 

Please share your great catches with your leader so they can be reviewed at the Daily Safety Briefing held at each campus. 

July Great Catch of the Month                                                            

The July Great Catch of the month comes from Soin Med Surg 5. Bentley Peed and Davida Vassar both responded to a bed alarm, and recognized the patient was choking. Both responders immediately took action to dislodge the obstruction, with Davida successfully administering the Heimlich maneuver. Their quick response to an alarm and reaction to the patient prevented serious harm from occurring. Thank you Davida and Bentley!                                           

Infection Control

Dependent Loops—A Significant Risk Factor for Catheter Associated Urinary Tract Infections

For urine to flow properly into the drainage bag of a Foley catheter, there must be a complete downhill path of the Foley tubing leading into the bag. When any part of the tubing forms a “hill” that the urine must travel over, this is called a “dependent loop,” and can double the patient’s chances for the development of a CAUTI. Dependent loops can be avoided by

  • Use of the green sheet clip to adjust Foley tubing so it is positioned properly
  • Coiling any excess Foley tubing onto the patient’s bed, making sure that it is not kinked and that the coil remains below the level of the patient’s bladder

Please see the pictures below showing an example of a dependent loop and of a Foley with correct positioning of Foley tubing:

Medication Safety

Heparin is a high-risk medication to prevent blood clots in patients. Heparin infusion therapy utilizes weight-based treatment protocols for indications such as DVT/PE/AFIB or ACS/MI/unstable angina.  Midas errors were reported where the dose is being entered in the rate field or vice versa in the ALARIS Pumps. 

  • Heparin infusion dose is calculated by weight as units/kg/hr
  • Do not confuse with rate which is designated as ml/hr
  • Heparin infusion doses are titrated based on anti-Xa levels
  • Dual-RN verification is required for new starts and dose changes
  • New feature in Epic MAR: Heparin calculator assists to calculate the dose based on the protocol and the anti-Xa level
September 10, 2021