Here are five little touches that can go a long way toward improving medication safety at your facility.
Be sure single-dose vials are discarded after one use. We put neon green stickers that read discard unused portion on medications that come in multi-dose vials, such as Flumazenil and insulin, to ensure they're treated as a unit dose and aren't reused. It's always been our policy to minimize the use of multi-dose vials, but given the recent events that have highlighted the risk of unsafe injection practices and cross-contamination (Google "Las Vegas hepatitis"), we've decided to go completely multi-dose free. The green labels are an extra step in that direction, at a minimal cost to us. We've also replaced 30ml multi-dose vials of saline for injection with single-dose, pre-loaded 10ml syringes.
Tag soon-to-expire drugs. On the first of each month, when we go through our drug stock to discard expired medications, we also place a small red sticker on drugs that will be expiring within the next two months. This helps indicate which drugs we'll need to order for the coming months and ensures that staff will use medications that are set to expire soon before opening new ones.
Educate patients about antibiotics.
The American Society for Gastrointestinal Endoscopy offers posters explaining its guidelines for the use of prophylactic antibiotics in endoscopy procedures (download a PDF at www.asge.org/WorkArea/showcontent.aspx?id=4298). Antibiotic treatment isn't frequently indicated for endoscopy, but many patients have questions because they may have had other procedures that did call for antibiotics. We post the ASGE's guidelines in our patient consult rooms to help educate patients about when these drugs are indicated.
Keep methylene blue on crash carts.
This drug, used to treat methemoglobinemia, a rare but life-threatening reaction to benzocaine, is stored on our crash carts instead of in our procedure rooms for easy access in an emergency. Because methylene blue requires weight-based dosing, we also keep a grid on the cart that calculates how many cc's are indicated for every 5kg.
Post emergency numbers. Our relationship with a local EMS service lets us call for an ambulance directly in the event of an emergency. But the seven-digit number is more difficult to remember than 911, so every telephone in the clinical area of our facility has a sticker with the number for the ambulance service in large print.
Tari Holterman, RN
Clinical Nurse Manager
Northern GI Endoscopy
Glens Falls, N.Y.
Traffic Control for Paperwork Problems
Nothing slows down case flow like incomplete paperwork. Who wants to track down a surgeon for signatures just to get a patient into the OR on time? We tried "sign here" stickers, but those either fell off or weren't easily seen by a surgeon in a hurry.
Now we paperclip red or green cards on the charts to let surgeons know their status at a glance. The red card means the paperwork isn't complete and the patient can't go back to the OR until it is. The green means the paperwork is complete and the patient's ready to move. The cards are four-inch by four-inch squares cut from colored file folders and laminated. We keep a stack of them at the nurses' desk. Our doctors like it because it prevents us from having to interrupt their post-op consults or other duties, and our pre-op nurses don't have to stop their work to get hold of OR staff.
Lacey Dyer, RN, BSN
Atlanta Sports Medicine Surgery Center
Remember, All Pain Is Local
Although many of my cases are performed with the patient under general anesthesia, I often inject the operative area with lidocaine, usually combined with epinephrine, to reduce operative-area pain and surgical trauma. The vasoconstrictor effect of epinephrine facilitates dissection and minimizes bleeding and, in turn, the need for electrocautery. For the same reason my orthopedic colleagues often use nerve blocks near the ends of many of their cases, I often spray the operative area with bupivacaine before wound closure so that the analgesia in the operative area continues into the early recuperative period. Most of the anesthesiologists with whom I work use IV ketorolac tromethamine just before the end of a case to minimize any general or local discomfort during the early recuperative period. Keep in mind that ketorolac tromethamine is contraindicated in patients who may be prone to bleeding and in surgical procedures in which bleeding can be problematic, such as a facelift.
Richard T. Vagley, MD, FACS
Pittsburgh Institute of Plastic Surgery
Is Your Pre-op Testing Early Enough?
A recent quality management review opened our eyes to the fact that one to two days before the day of surgery didn't leave nearly enough time for thorough pre-op testing. Sometimes it was difficult to catch an abnormal lab or EKG, sometimes lab work or H&Ps were missing.
Cancelled cases are expensive for the doctor, for the patient and for the supply budget, if you've already set up for a case when you realize it'll have to be postponed. But by starting earlier, we don't have to cancel as many.
We recently began conducting our pre-op testing nine days before the day of surgery. Up to two weeks ahead of time would be ideal as well, as that gives you enough time to get the H&P from the referring surgeon on a timely basis and to get EKG results.
Why nine days? We'd originally also used the pre-op testing to test total joint replacement patients for MRSA before they arrived. That gave us a five-day window for treatment in the event that a patient tested positive. (Now our orthopedic surgeons take care of the MRSA testing during office consults. But we're still considering implementing it hospital-wide.)
We've also changed our staffing process for pre-testing. We make sure there's a one-to-one nurse-to-patient ratio. When a patient comes in for testing, we'll have a nurse assigned to the case.
The earlier, more complete testing and the attentive staffing has had noticeable results, the most significant of which is that, by our counts, the time from a patient's arrival at the desk for testing to their release has decreased from 76 to 46 minutes.
Diana McDaniel, MSN, CASC
Manager of Perianesthesia Services
Turn Off Lights in Unexpected Places
Throughout our health system of five hospitals and two nursing homes, we're looking for ways to save energy and money and to decrease our carbon footprint. We performed an energy audit and learned that the dozens of soft drink vending machines around the hospital essentially big refrigerators were consuming large amounts of electricity. We removed several and turned off the lights in the remaining machines. This will save us more than $10,000 a year.
Office computers sap a lot of energy. We encourage everyone to turn off their computer and any peripherals printers or scanners when they leave at day's end. This doesn't have to be a hassle. We use Smart Strips power strips ($40 each) that automatically turn off the peripherals and monitors once they sense that the computer is off. The return on investment will take just a few months.
Our sustainability committee also encourages staff to pursue little efforts that make a big difference, such as reducing elevator use by taking the stairs for short trips; recycling printer cartridges, paper, aluminum and plastic; and bringing a mug to work instead of using disposable cups. We stress, "reduce, reuse, recycle." We're even looking into producing biodiesel from waste cooking oil.
Ravindra Gupta, MD
Hospitalist and Co-Chair of Inova Health System Sustainability Committee
Inova Health System
Falls Church, Va.