AACN News—March 2009—Practice

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Vol. 26, No. 3, MARCH 2009

Practice Resource Network

QIn our unit we currently use a medication calculation assessment tool for newly hired, experienced ICU nurses. The IV pumps we use make dosage calculations for the nurse, decreasing the chance of human error as long as the patient and drug information is entered properly into the IV pump. Should we continue to teach and test nurses on medication calculations when it is unlikely they will ever be required to calculate medication dosages in the ICU?

A The advances available in bedside healthcare technology today have helped improve patient safety. In particular, “smart” infusion pumps with large-dose libraries and complex calculation algorithms have provided an extra level of safety for patients. However, studies are finding that despite patient care technologies such as smart infusion pumps and bedside computerized documentation among others, errors still happen. Sometimes, the technology fails but the main reason these technologies are involved in patient care errors is that they all require a human interface. The Joint Commission released a Sentinel Event Alert in December 2008, “Safely implementing health information and converging technologies.” It states the following, “The overall safety and effectiveness of technology in health care ultimately depend on its human users, ideally working in close concert with properly designed and installed electronic systems. Any form of technology may adversely affect the quality and safety of care if it is designed or implemented improperly or is misinterpreted. Not only must the technology or device be designed to be safe, it must also be operated safely within a safe workflow process.”1 An article in the January issue of the ISMP Medication Safety Alert Nurse Advise-ERR newsletter describes a serious error that occurred despite the use of smart infusion pumps. Upon investigation it was discovered that the staffbypassed the dose-checking technology. In the article, six factors were identified as contributing to the staff choosing to bypass the technology:

• Falsely assessing low perceptions of risk
• Failure of the organization to make adjustments in the drug library
• Extra steps required to use the technology
• Time pressures
• Clinical emergencies
• A culture that inadvertently supports at-risk behaviors including technology work-arounds

In the critical care environment, accurate administration of potent vasoactive medications is imperative. While smart infusion pumps and computerized bedside documentation systems are tools that can help ensure accuracy, it is the critical care nurse who is responsible and accountable for the outcomes. Critical care nurses must have an understanding of medication calculations in the event that the technology fails or is unavailable, when a clinical emergency develops and to validate the correct infusion rate.

What Can You Do?
• Develop a culture of safety in your unit. This means creating an environment that does not support bypassing the technology.
• Analyze the pump logs and collaborate with the clinical pharmacists to make sure the drug libraries are reviewed and updated regularly.
• Evaluate all pump overrides.
• Have medication calculation references readily available on the unit, at the nurses station, in the patient rooms and wherever else they are necessary to promote critical thinking.


1. The Joint Commission. Sentinel Event Alert Issue 42. Safely implementing health information and converging technologies. Published December 11. 2008. Accessed January 19, 2009.

2. The Institute for Safe Medication Practices. Smart pumps are not smart on their own. Published April 19, 2007. Accessed January 19, 2009.

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Beacon Corner - Best practices submitted by Beacon Award recipients

‘Strip and Flip’ – One Unit’s Performance Improvement Project
By Sarah Rosenlund, MHS,RN,CCRN
Nurse Manager, CVICU
Saint Alphonsus Regional Medical Center, Boise, Idaho

Using the PDCA (Plan, Do, Check, Act) format for process improvement, the CVICU at Saint Alphonsus embraced new documentation and assessment guidelines. We implemented an initiative to improve computerized documentation in several areas: restraints, suicide precautions and skin impairment. How we adopted a new plan for initial skin assessment, interventions and documentation is the focus of this article. Restraint and suicide precautions were presented at the same time. The staff adopted the documentation project in a fun and engaging way.

Plan – The identified problem was documentation of initial skin assessments on new patients. If a skin breakdown was noted on admission the nurses needed to document interventions to promote healing and/or reduce the potential for an increase in the breakdown. Posterior (occipital, ears, coccyx and heels) areas were inconsistently assessed for breakdown in the documentation on new patients. The required skin assessment was not always being thoroughly documented with interventions of the breakdown being noted. The hospital’s Performance Improvement Team and the Education Department put a plan together to train Super Users on each unit, and they became the change champions for assessment and documentation.

Do – The CVICU has a fun work environment, and our Super User for this project is a very energetic and positive young nurse. At the staff meeting following the Super User training, she presented the information and expectations. She coined the phrase “Strip and Flip” for the assessment. It became a hit, and the staff would ask if “the patients had been stripped and flipped” on admission. Even some of the patients laughed about the phrase. Posters were also hung in the staff restroom.

Check – Our computerized system allows the documentation of the Braden Scores to be audited. Our CVICU has seen an improvement in the thoroughness of the skin assessments and documentation of interventions from these chart audits. They have moved from an 80 percent compliance rate for documentation of the Braden Score of “less than 23 with interventions” in March to 95 percent compliance in April. Since then the unit has been consistently 95 to 100 percent compliant.

Act – The CVICU nurses embraced the plan and adopted it as the unit standard for admission skin assessment, interventions and documentation. We currently have computerized nursing documentation, but will be changing to a new system. This is an example of nurses embracing change and finding their own way to incorporate it in a healthy work environment, for one another and to improve patient outcomes.

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