MEDICATION MADNESS Look-alike drugs can easily lead to a mix-up.

In the never-ending quest to keep your patients safe, all allies are welcome, be they new products, new techniques or new ways of thinking about safety. We spoke to surgical facility leaders about their most innovative ideas to enhance patient safety. Feel free to borrow what's worked for them.

1. Medication errors
Medication errors can be a costly and deadly mistake — and one that's largely preventable, says Steven G. Vitcov, MD, medical director of the Presidio Surgery Center in San Francisco, Calif. To prevent mix-ups with look-alike, sound-alike medications, his center purchases pre-filled, pre-packaged versions of the most commonly confused drugs from compounding pharmacies.

"Sometimes you get drugs that are in vials that look identical," he says. "There have been a lot of incidents reported across the country of doctors grabbing a vial and giving it to the wrong patient or at the wrong concentration. These medications help prevent that."

Pre-filled medications are more expensive, he says, but they come in syringes with big, bright labels noting their name and dose. Not only does this packaging help prevent medication errors, but the single-dose supplies also increase safe injection practices and help eliminate problems that can occur when surgical teams are left to mix or dilute concentrated medications. For example, he says the concentration phenylephrine typically comes in would likely kill a person. "The 1 cc vials contain 10,000 mg, but the actual dose is 100 times less," says Dr. Vitcov. "We now stock the correct, diluted dose instead."

Even with clearly labeled medications, there's still a chance of giving the wrong medication to the wrong patient. Joseph Moffa, MSN, BS, RN, NE-BC, CCRN, nurse manager of PACU at the Hospital of the University of Pennsylvania in Philadelphia says that's where his hospital's electronic medical record system comes into play. Here's how it works: A bedside nurse delivering drugs to a patient first must log into the patient's EMR. Then, she can scan the drug using an iPhone or special barcode scanner connected to a mobile tablet. After scanning the medication, the EMR will confirm the patient's name, the drug and the dosage, and tell her whether it's okay to proceed or if she has the wrong one. The mobile barcode system, which is included as part of the hospital's new EMR software, not only helps confirm that the medication is correct, but also holds staff accountable. "If someone bypasses it, the admin can tell," says Mr. Moffa. "You can see how many meds haven't been scanned, and who didn't scan them."

BETTER PREPARED Some facilities are stocking fast-acting dantrolene that's easier to prepare in a malignant hyperthermia emergency.

2. Malignant hyperthermia
Dantrolene has been the standard for treating malignant hyperthermia emergencies for decades. But it can be difficult and time-consuming to reconstitute the antidote in a time of need, says Mr. Moffa. That's why his hospital recently started stocking a new fast-acting dantrolene instead.

Dr. Vitcov's facility has also made the switch. The new drug not only takes less than a minute to administer, he says, but it also requires less storage space and manpower for reconstitution. For traditional dantrolene formulas (including Revonto and Dantrium), facilities must keep 36 20-mg vials on hand and add 60 ml of water per vial for reconstitution during an emergency. The new formula (Ryanodex) requires facilities keep only 3 250-mg vials on hand. A single bottle acts as an initial dose in an emergency and requires only 5 ml of water, says Dr. Vitcov.

"It's traditionally been a laborious process to administer this drug," he says. "Not only does it take up a lot of physical space, but there's also a lot of physical activity involved. If an emergency happened when we were short-handed, like towards the end of the day, it would be difficult to mix and deliver it."

The new formula does come with a few tradeoffs, though, including a high price tag and a shorter shelf life. With improving pre-op MH screening protocols, this could mean leaving thousands of additional dollars sitting on the shelf only to expire. Despite those concerns, Dr. Vitcov says his center thinks it's worth the investment. "It is about 3 times the price (of standard formulas)," he says. "But it ended up being an easy sell to the financial arm of the center because we don't want to have a patient die of MH."

PREVENTING VTE Continue patients' prophylaxis for venous thromboembolism at home with take-home sequential compression devices.

3. Venous thromboembolism
For facilities performing outpatient orthopedic procedures, take-home sequential compression devices can help reduce the risk of venous thromboembolism (VTE), says Lisa Herder, RN, BSN, nurse manager of Beaver Sports Medicine Surgery Center in Corvallis, Ore. After recently seeing an uptick in VTE cases after discharge, Ms. Herder says her center is developing a blood clot prevention program that includes the use of take-home SCDs, as well as better pre-op screening and post-op education of patients.

"When patients score over a 5 (using the Caprini scoring system), they get compression stockings," says Ms. Herder. "For these high-risk patients, though, we wanted to add battery-operated pneumatic devices."

Creating this type of program is especially helpful for total joint patients who are "a little more bedridden" than typical outpatients, says Robert Morsut, RN, ADN, OR clinical coordinator for Peachtree Orthopaedic Surgery Center in Atlanta, Ga. "With the stepping up of our total joint program, we started a take-home system," he says. "Patients put the disposable SCD sleeves on at home, they simply push the button and it does the compression for them. Then when they're done with recovery, they receive a cardboard envelope to mail the pump back."

When shopping around, Ms. Herder recommends looking for cordless devices — to help avoid tripping hazards — that also feature user-friendly interfaces. Also consider the company's level of involvement in the process: Some handle all of the billing of patients' insurance and maintain the devices, while others will sell the SCDs directly to your facility. Ms. Herder's center went with the latter option in order to "cut out the middleman."

BETTER PROTECTION Help prevent patient pressure injuries by using the latest memory-foam and viscoelastic-gel positioners.

4. Patient positioning
Preventing pressure injuries requires proper positioning and padding. To make the job easier, manufacturers have created several position-specific devices for your trickier cases, including head protectors and mats that reduce sliding in Trendelenburg, special table attachments for hip and knee cases and even padded hand positioners for surgeons performing wrist surgery.

One especially problematic position is prone, which can cause blindness if excessive pressure is placed on the patient's ocular nerve, says Mr. Morsut. For patients in this position, he says staffers use a special memory-foam device that distributes pressure evenly around the face. It features cutouts for the eyes and a mirror underneath it to let anesthesia better monitor patients during the procedure.

Positioning is especially important in spine cases, where patients are left in prone position for extended amounts of time, says Mr. Morsut. For these cases, the center uses a special bed frame that cushions the patient's pressure points while cradling his body into a gentle "C" shape. "They're going to be in that position for more than an hour, so they need to be well-cushioned," he says. "Basically, the patient is completely cushioned from their neck down to their feet."

When considering new pads, rolls and other positioners, Mr. Morsut suggests looking at options featuring viscoelastic gel, which works well for high-risk patients. "They disperse patient weight more evenly," he says. "We try to stay away from foam, since it compresses down too much sometimes and doesn't give a large surface area for the patient's mass to dissipate."

SWAB TREATMENT Swab high-touch surfaces like keyboards to make sure you're not cross-contaminating.

5. Cross contamination
Don't forget about the behind-the-scenes patient safety players in your central sterile processing department. The latest lumen-flushing devices, low-temperature sterilization units and manual cleaning aids can give your techs a leg up in the fight against cross-contamination. For Donna M. Mavrelos, RN, BSED, CNOR, RNFA, CRCST, sterile processing manager at Nemours A.I. duPont Hospital for Children in Wilmington, Del., that includes 2 devices the hospital recently added to ensure proper cleaning of an instrument before sterilization or high-level disinfection. In the OR, staffers use a point-of-use cleaning kit that contains slim tubes filled with enzymatic detergent. After the surgeon is finished with a robotic, laparoscopic or other slim instrument, its tip is inserted into the tube to keep it moist and start the cleaning process. "Think of the plastic tubes that hold fresh-cut roses," she explains.

After the instrument arrives in central sterile and is scrubbed clean, it is swabbed as part of the hospital's cleaning verification system. The swab is then checked for missed protein using a hand-held luminometer. "We do upwards of 10,000 trays a month," says Ms. Mavrelos. "We probably perform 15 to 30 swabs per day, randomly. If we see something that's not clean, we send it back to repeat the process."

It's not just the instruments that get the swabbing treatment. "We do other things, too, because everything is contributory," she adds. "We swab everything from handles, to doors, to desks, to keyboards, to telephones, to even staffers' hands, just to make sure we're not contaminating the clean instruments.

"Patient safety is always No. 1," says Ms. Mavrelos. "There's no guarantees of anything in life or sterile processing. But any technology that can help, we'll consider." OSM