Patient Safety Officer Executive Development Program



Oxytocin: High Alert Medication Deep DiveGetting StartedPerinatal Improvement CommunityBackground:On August 9, 2007, oxytocin was designated as a high alert medication by the Institute for Safe Medication Practices (ISMP)- see appendix. The use of oxytocin is significant on L&D Units across the U.S. and concerns related to Perinatal harm and liability led to the development of the IHI Oxytocin Bundles. Considerable concern exists regarding the variation and the reliable administration of oxytocin. This tool is currently being tested by the IHI Perinatal Improvement Community to assist teams to evaluate the safety of their environment while oxytocin is administered at a system level. The goal is to establish a system linkage with structure/process/outcomes.Supporting References:JCAHO Standard MM.7.10 The organization develops processes for managing high-risk or high-alert medications. JCAHO defines high-risk and high-alert medications as medications involved in a high percentage of medication errors or sentinel events and medications that carry a high risk for abuse, error, or other adverse outcomes. JCAHO requires organizations to identify high-risk and high-alert medications used within the organization. National lists, as well as organization-specific data, on drug use should be used for defining the drugs considered high risk or high alert by the organization. The organization also must develop additional processes for selecting, procuring, storing, ordering, transcribing, preparing, dispensing, administering, and monitoring these high-risk and high-alert medications. ISMP Alert, August 9, 2007. Oxytocin was named a high-alert medication in 2008. High alert medications require special safeguards to reduce the risk of errors. This may include strategies like improving access to information about the drug; limiting access; using auxiliary labels and automated alerts; standardizing the ordering, storage, preparation and administration; and employing redundancies such as automated or independent double checks when necessary. Available for free download at Simpson, Kathleen Rice. Measuring Perinatal Patient Safety: Review of Current Methods. JOGNN. 35, 432-442. 2006.The Deep Dive is intended to be repeated every six months- usually prior to a face to face meeting to measure your progress.Steps in the ProcessMeet as a team to review the toolIdentify a 2 week period to review the records of all patients who received oxytocin (>37 weeks or term by ACOG definition)Review records with as much team participation as possibleCollate results and share at a team meeting. Post to your team homepage on the ExtranetIdentify your opportunities and relate this to your AIM for the Perinatal CommunityCelebrate what you do well and share with the entire unitSchedule a meeting with Sue Gullo to review your results and next step if needed sgullo@Insert results into your Meeting Storyboard (storyboard instructions and materials will be sent out one month prior to in person meeting)StructureYesNoN/A1. Interdisciplinary Fetal Monitoring Education2. Documentation tools consistent with NICD terminology 3.Weekly fetal monitoring strip and case reviews (or (#4)4. Monthly fetal monitoring strip and case reviews5. Standard mixture and policy for oxytocin administration6. One standard administration order set7. If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed. 8. Team definition for tachysystole9. Clinical algorithm for identification and management of tachysystole10. Clinical algorithm for management of indeterminate/abnormal FHR patterns (NICHD 2009)11. RN empowered to call cesarean team (not to diagnose the need for cesarean, but to activate the team)12. RN empowered to call neonatal team13. Consistent handoff tool {SBAR, etc} specify14. Informed Consent for oxytocin administration15. Individual Provider data published about induction/augmentation rates?*The Faculty would also like the team to note specific individual provider/nurse practice patterns while reviewing all records during the 2 weeks which may be used internally to identify further opportunities to reliably deliver oxytocin.Link to high alert medicationLink to Oxytocin BundlesStructure Document Directions: Interview at least 5 different people on the unit (Nurses, Physicians) to determine if they all share the same yes/no answer on these questions. It will assist you in identifying any gaps from policy/procedure to care delivery at the patient level. Example: A nurse on weekends or nights may not have the same answer as a nurse on the day shift during the week.ProcessYesNoExplanations to support the process questionsCareful Monitoring- 1. Appropriate level (high risk) based electronic fetal monitoring (or IA) for fetal heart rate and uterine activity while oxytocin administered.(Per Perinatal Guidelines)High risk- every 15 minutes during the active phase of the first stage of labor. Every 5 minutes during the second stage of labor2. Oxytocin initiated as intended – no delay in administration due to provider or nursing response. Was there a delay in initiation or during administration due to provider unavailability, nursing staffing, provider staffing issues?Timely Identification-3. □Tachysystole identified and managed according to protocol /algorithm□Tachysystole identified and managed according to team definition and standing ordersIf tachysystole was not present, please make sure you note this in this column but do not collect information on yes/no unless it is present.□ No tachysystole present4. □ Indeterminate/abnormal FHR identified Note in this column if reassuring/normal status always present.Appropriate Interventions-5. Oxytocin dose decreased or discontinued during labor due to tachysystole?__________#times6. Oxytocin dose decreased or discontinued during labor due to FHR?__________#times7. Oxytocin resumed after a decrease or stop?Decrease or stop related to the presence of tachysystole or non-reassuring FHR. Other?8. Terbutaline administered?9. Interventions needed?Interventions may be change in position, IV fluid bolus, and emergency cesarean.10. Once labor was progressing, was oxytocin discontinued?Was oxytocin stopped when labor pattern was effective?Activation of Team Response11. Documentation of physician notification of change in dosage of oxytocin.12. If requested, timely response by OB care provider for bedside evaluation.13. Escalation plan in place if needed and documented.If tachysystole or indeterminate/abnormal FHR noted, was provider supportive of decision to discontinue medication?14. Documentation of oxytocin dosage and pattern of administration during handoff.15. Day of week______________ 16. Shift/Shifts care delivered__________Opportunity to determine if patterns of administration are standard or subject to other influences.Outcomes (T=from Perinatal Trigger Tool)*YesNoComments 1. (T1) Apgar <7 at 5 min 2. (T2) Admission to NICU3. (T7) 3rd or 4th degree laceration4. (T9) Blood Transfusion5. (T18) Instrumented delivery6. (T15) Excessive blood loss7. (T16) Neonatal Injury (e.g. fractured clavicle).8. (T20) Cord gas < 7.209. (T22) Other Shoulder dystocia10. Cesarean Section*Identification of these triggers as an outcome in this tool is a different process than the Global Trigger tool process. It does not include the assignment of harm (we will explain this further as you move forward in the Community).NOTES: ................
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