Provider issues related to patient controlled analgesia and nurse controlled analgesia errors in a pediatric hospital

Background: Medical errors are a danger to patient safety and a significant cause of morbidity and mortality. Additionally, they increase expenditures in an already significantly indebted U.S. health care system. Much confusion exists about definitions of medical errors, which include medication errors and adverse drug events (ADEs). Several federal and international organizations have attempted to standardize definitions in order to streamline data collection, but until these standards are universally adopted, error reports and trends are still subject to questions of validity. Reporting errors, in general, has become a more socially acceptable practice in health care with the advent of several anonymous reporting databases. There have also been several initiatives aimed at reducing the incidence of errors, which range from national programs to intrafacility guidelines. Several pieces of health information technology (HIT) have made an impact on error incidence and data collection, although there is much room for improvement. Patient controlled analgesia (PCA) pumps for pain management have been in existence for decades, and "smart pump" software has improved their safety and ease of programming. PCA use in children presents challenges to clinicians, and the characteristics of providers who write PCA orders and those who program PCA pumps may play a role in the incidence of events related to PCA. This study seeks to elucidate trends in errors as they related to these different PCA providers in a pediatric hospital in the northeastern U.S. and provide recommendations for how PCA practice can be improved in this facility. Methods: Safety Event Reporting System (SERS) reports of PCA events (n = 117) during the period of 2004 - 2012 were analyzed retrospectively to determine several key variables for data analysis. The main focus of this analysis was those variable trends related to providers, including: proportion of events caused by human error, proportion of events related to subcategories of human error, proportion of types of prescribers involved in PCA events, proportion of errors in medical and surgical patients, proportion of errors occurring on day and night shifts for the nursing staff, and proportion of events that were dosing mistakes. Statistical analysis was performed for these results when possible to determine significance. Results: Human errors were implicated in 84.1% of events, whereas PCA pump mechanical errors and software errors were implicated in 7.1% and 7.9% of events, respectively. Statistically significant differences were found in all variables tested, including the proportion of nursing errors (60.9%) versus prescriber errors (28.7%) (p < 0.0002). For types of prescribers, the proportion of PCA events occurring when a M.D. wrote the PCA order (56.41%) was statistically different than when a N.P. wrote the PCA order (39.32%) (p = 0.0129). More surgical patients (61.5%) were affected by PCA events than medical patients (36.8%) (p < 0.0002). There were more events occurring on the nursing staff day shift (59.8%) than the night shift (36.8%) (p = 0.0004). Finally, dosing mistakes (66.7%) were implicated in significantly more PCA events than any other error type (33.3%) (p < 0.0002). Conclusion: Several recommendations for improving the safety of PCA in pediatric pain management are justified by the results of this data analysis. First, further education and simulation for entering PCA orders into the CPOE system is needed for all prescribers. Secondly, further education and simulation in PCA pump programming and system set-up is needed for all nursing staff members. In regard to prescriber credentials, it is recommended that Pain Treatment Service (PTS) staff members train M.D. residents in writing PCA orders and entering them into the CPOE system. Finally, it is recommended that the SERS management team publish standardized error report content and entry format in order to streamline data analysis for quality improvement (QI) purposes

Anesthesia Provider Education on the Adherence to the Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting

Background and Review of Literature: The occurrence of postoperative nausea and vomiting (PONV) has been linked to unplanned admissions, longer post-anesthesia care recovery units (PACU) times, and decreased patient satisfaction. The Fourth Consensus Guidelines for the Management of PONV released new guidelines in 2020 outlining evidence-based practice to manage PONV. A literature review was conducted on a total of 10 studies. The findings support the methods these guidelines employ. Purpose: This quality improvement (QI) project aims to provide education for anesthesia providers on the fourth consensus guidelines and improve provider adherence. Methods: A six-minute educational video, post-education quiz, provider demographic questionnaire, the electronic medical record (EMR), and Apfel simplified risk score was used to gather information on the usefulness on education of these guidelines to improve adherence. Implementation Plan/Procedure: An educational video on guidelines one, two, and three was emailed to Certified Registered Nurse Anesthetists (CRNAs) in pod 1 with a post-education quiz and provider demographic form. A total of 10 CRNAs were selected with five EMR charts being reviewed per provider at four separate intervals (retrospective, 2-week, 4-week, 6-week). Apfel score, procedure type and length, anesthesia student presence, and medications administered were evaluated through the EMR. Findings: Out of the 10 CRNAs who agreed to take part in the study, only six completed the study. No statistically significant change in guideline compliance was found after providers received education on the guidelines when compared to compliance prior to education

Effects of Pediatric Emergence Delirium Education on Analgesic Administration by PACU Nurses

Emergence delirium (ED) is a behavioral disturbance as a result of general anesthesia that commonly occurs in pediatric patients. Adverse effects of ED lead to a complicated recovery from anesthesia due to the risk of self-inflicted injury of patients, the disturbance of surgical incisions, the development of postoperative maladaptive behaviors, and the increased use of sedatives and analgesics resulting in prolonged recovery time and delayed discharge from the post-anesthesia care unit (PACU). Due to the multiple ramifications of ED, appropriate care is needed to promote a safe recovery from anesthesia and an optimum perioperative experience for these patients. As PACU nurses are the primary providers of care to this population group during the occurrence of ED, it is imperative they are able to recognize and manage ED appropriately. The goal of this evidence-based practice project was to increase the knowledge of ED among PACU nurses and determine its effects on analgesic usage among pediatric surgical patients in the PACU. Using the Iowa model of evidence-based practice in developing quality care, an educational session on ED was developed and provided to PACU nurses of a large, Midwestern hospital in regards to the identification of the occurrence, associated risk factors, multifactorial causes, and effective treatment options for ED. A two-group comparative design was used based on medical records selected using a convenience sampling. Pre-intervention group data was collected from 28 samples prior to the educational sessions and post intervention group data was collected from 24 samples after the implementation. Findings revealed an overall decrease in analgesic use with a significant decrease in the use of stadol, while the use of acetaminophen and fentanyl increased. Data also demonstrated higher PAED scores correlated positively with weight and being of Hispanic race. The results of this EBP project lend limited support for the use of ED education to affect analgesic usage among PACU nurses

Perioperative Care

Perioperative care practices worldwide are in the midst of a seeing change with the implementation of multidisciplinary processes that improve surgical outcomes through (1) better patient education, engagement, and participation; (2) enhanced pre-operative, intra-operative, and post-operative care bundles; and (3) interactive audit programs that provide feedback to the surgical team. These improved outcomes include reductions in the frequency and severity of complications and improved throughput, which ultimately reduce operative stress. Practices in theatre as well as ward are becoming more collaborative and evidence-driven.This book is best utilized by perioperative care team members engaged in quality improvement, collaborative practice, and application of innovations in surgical care

Factors Associated with Pharmaceutical Venous Thromboembolism Prophylaxis in Hospitalized Surgical Patients.

Despite evidence that venous thromboembolism (VTE) is one of the most preventable causes of death, pharmaceutical prophylaxis is underused. It is unclear why such evidence-based risk assessment and treatment is often omitted or delayed. One unexamined factor is nursing’s role in the administration of prophylaxis, and the nursing work environment. This study applied a theoretical framework of situational awareness, recognized by high reliability organizations (HROs) as a critical component in daily operations, to an important problem: VTE prophylaxis. This retrospective cohort study, utilizing data from the Michigan Surgical Quality Collaborative (MSQC), the electronic medical record, and the staffing system, aimed to examine environmental factors associated with 1) the administration of pharmaceutical VTE prophylaxis, 2) VTE occurrences, and 3) other postoperative occurrences. The sample included patients from a single institution in the MSQC database who were hospitalized for at least 24 hours and remained on the same unit (N=1,370). Correlations and logistic regressions were used to analyze the data. Nearly one-third of patients experienced an error. Significant predictors included VTE risk score, the difference between actual and budgeted RN hours per patient day (RN HPPD), census, workload, education, and unit type, all in expected directions. As the gap in RN HPPD decreased, patients were 12.4% more likely to receive prophylaxis. Patients were less likely to receive prophylaxis as nursing workload increased. The more baccalaureate-prepared nurses on the unit, the more likely patients received prophylaxis; a 1% increase corresponded to a 4% decrease in patients not receiving necessary prophylaxis. Patients admitted to surgical units were four times more likely to receive the prophylaxis. Patients who received prophylaxis were less likely to have a VTE occurrence. This is the first study to examine the environmental factors of situational awareness and patient outcomes. Situational awareness is recognized as a contributing factor in HROs to manage and reduce risk. Future work is needed to extend this research and contribute to an understanding of how the nursing work environment impacts patient outcomes in a high reliability organization. The findings from this study have potential to extend our understanding of the complex work in nursing.PhDNursingUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/120647/1/arenard_1.pd

Documentation: Delirium in the Hospitalized Older Adult

Background: Delirium is a common, life threatening and preventable geriatric syndrome. Because this condition is frequently addressed by administering dangerous antipsychotic drugs, it is imperative that accurate systematic assessments are charted to determine the actual need for these medications. The purpose of the study was to describe medical record documentation of a systematic assessment of delirium in older adults who had been administered an antipsychotic medication. Methods: A descriptive correlational retrospective design was used for this medical record data based study. The setting was a 107 bed acute care community hospital located in southern California. Inclusion criteria were medical records of patients who were 65 years or older, admitted to a medical/surgical/telemetry unit and had received lorazepam or haloperidol. Descriptive and inferential statistics were conducted using SPSS version 18. Results: For the total participant cases (N=70), age 65 to 97 years, and 60% female, there was no documentation of a systematic delirium assessment. Therefore, associations between a documented systematic assessment and other select variables could not be determined. However, antipsychotic medications were prescribed more often to females than males (p=.003). Conclusions: This study examined the documentation of a systematic assessment for delirium in hospitalized older adult patients who had been medicated with select antipsychotic medications. Documentation of a systematic assessment of delirium is important so causative factors can be remedied and appropriate interventions put into place to not only keep the patient safe, but hopefully improve the outcomes of hospitalized older adults

The Journal of BSN Honors Research, Volume 5, Issue 1, Summer 2012

University of Kansas School of Nursing. Bachelor of Science in Nursing Honors ProgramExploration Of Health Care Needs Among Sudanese Refugee Women - Albin, J M, Domian, E. Is There An App For That? Developing An Evaluation Rubric For Apps For Use With Adults With Special Needs - Buckler, T, Peterson, M. The Relationship Between Nursing Characteristics And Pain Care Quality - Davis, E, Dunton, N. The Relationship Between Sleep And Night Eating On Weight Loss In Individuals With Severe Mental Illness - Huynh, Thu Nhi, Hamera, E. Examining Nurse Leader/Manager-Physician Communication Strategies: A Pilot Study - Jantzen, M, Ford, D J. Comparison Of Personal, Health And Family Characteristic Of Children With And Without Autism - Martin, A, Bott, M J. Association Between Obstructive Sleep Apnea And Postoperative Adverse Events - Nielsenshultz, Y, Smith, C, Bott, M, Schultz, M P, Cole, C. Challenges Associated With Partnering With Sudanese Refugee Women In Addressing Their Health Issues - Pauls, K L, Baird, M B. Complementary Therapy To Relieve Pediatric Cancer Therapy-Related Symptoms In The Usa - Slaven, A, Williams, P D

The pharmaceutical services to the elderly in the old aged homes in Hong Kong: a scope exercise

Various models of pharmaceutical services have been provided by pharmacists to old aged home residents, however, these models have never been summarised and compared. The aim of this scoping exercise is to identify different kinds of pharmaceutical services currently available to the old aged home residents, by means of systemic literature review, qualitative in-depth interviews with service providers in order to understand their models and qualitative semi-structured interviews with non-pharmaceutical service users in an attempt to investigate reasons why some homes do not subscribe to these services. The results showed that none of the pharmaceutical services currently available can uproot the causes of medication errors, and there is a need to elaborate the roles of pharmacists in a primary care setting.link_to_subscribed_fulltex

Drug wastage among the elderly living in old aged homes in Hong Kong

The extend of drug wastage among elderly living in old aged homes was never investigated. Upon the completion of the previous study on pharmaceutical services provided to elderly living in old aged homes, the amount of drugs wasted from 3,020 residents in one of the delegated pharmacies over a 4-month period were counted and their costs were calculated. The total cost of wasted drugs amounted to be HKD$96,924, with drugs acting on the central nervous system contributed to the highest cost of HKD$26,872 (27.7%), followed by respiratory drugs of HKD$23,875 (24.6$22,965 (23.7%). The results showed that for health institutes dispensing prescriptions of long duration to the elderly could lead to considerable amount of drug wastage and this issue should be addressed.link_to_subscribed_fulltex

Does better documentation compliance with ERAS protocol translate to improved clinical outcome?

Aim: Enhanced Recovery After Surgery (ERAS) programmes involve multimodal optimisation of patient care throughout their surgical stay. The aim of this study was to determine if better ERAS protocol documentation compliance was associated with improved clinical compliance and better clinical outcomes. Method: A retrospective cohort study was conducted of 97 (F=50) patients enrolled in the hospital’s ERAS programme over two 4-month time periods in consecutive years, 2019 and 2020. Three ERAS pathways were used, 1) bowel resection with stoma, 2) bowel resection without stoma, and 3) closure of stoma. Outcome measures were benchmarked against key ERAS aspects. Results: Approximately 45% of patients on the bowel resection with stoma and closure of stoma pathway met the ERAS benchmark. Patients on the bowel resection without stoma pathway had the poorest compliance at only 26%. Many instances of incorrect pathway allocation and poor documentation occurred, while only 62% of patients did not complete the pathway form. Conclusion: This study has shown that there is no correlation with better documentation to improve clinical outcomes on the ERAS pathway. It has also provided an insight of the ERAS culture in our organisation. Our findings suggest that pre-admission counselling is a significant part of ERAS as this sets the expectations for patients and the need for a dedicated person to provide this counselling, as well as continuous collaboration and education to staff so they could provide the right advice for patients..In terms of the documentation on the ERAS pathway, the responsibility should be shared across the multidisciplinary team