Slide 1

Report
Christopher Patty, DNP, RN, CPPS
Kaweah Delta Medical Center
Visalia, California
“The hospital is great at adding
things for nurses to do, but they
never take anything away”
Addiction (def.)
“Compulsive engagement in rewarding
behavior despite adverse
consequences”
•The DV process induces many
distractions, interruptions, procedural
failures and clinical errors
•Nurses hate it
•Patients aren’t crazy about it either
Distraction (antonym: concentration) is
something I do to myself “…I need to
find another nurse to DV this insulin”
Interruption is something I do to
someone else…”Hey, will you check
this insulin with me?”
•DV can reduce errors by 30% if done
correctly
•Two clinicians separately check;
•Alone and apart from one another;
•Then compare results;
•For prescribing, dispensing and verifying
•DV is inconsistently practiced (Brannan,
2010)
•Errors occur despite DV (Armitage, 2008)
•DV becomes superficial routine task
(Smetzer, 2003)
•Staff aren’t really doing independent double
verification
•Staff treat DV as a mindless robotic rote task
•Deviance from ideal practice has been
normalized
•Staff cannot articulate prevented errors
•Every insulin error has been in the DV era
•40% of SQ insulin doses are 1 unit
•All our orders were in paper charts
•We did the transcribing/decoding
•Before pharmacist’s prospective review of
orders
•Before automated dispensing cabinets
•Before barcode medication administration
•Before POC blood glucose testing
•Before 1/3rd of our patients were diabetic
“Our safety consulting staff recommends
independent double checks for IV but not SQ insulin,
because these almost certainly will not be properly
conducted due to volume of doses needing a check”
“We are fine if any individual nurse giving
subcutaneous insulin wants to ask for a check by a
second individual, but we don't believe it should be a
requirement in most situations.” – Michael Cohen,
April 2013
“Independent double-checks must be strategically
placed for just a few high-alert medications”
•It’s required by JCAHO, Title 22, CMS, etc
•That’s the way I was trained
•Insulin is a “high alert” medication.
•Patients die from insulin overdoses!
•Two heads are better than one
•Better to do something than do nothing.
•Everyone else is doing it
•We’ve always done it that way
•It’s policy
•We don’t want to stop for the wrong reasons
•Reduces the number of distractions
and interruptions during medication
administration
•Keeps nurses and patients together
•Allow nurses to practice to the full
extent of their licensure (IOM, 2011)
•Avoid waste in all its forms including
wasted thought (IOM, 2001)
Volume of SQ Insulin Doses vs. Time of Day, 1 Week/Unit
160
140
140
120
100
100
88
80
70
60
40
20
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
“When you need me to double-verify your
insulin, I’m in the middle of giving mine”
•Patient Safety
•No change in glycemia profiles pre- and postintervention
•No change in self-reported ADE pattern
•Nurse Satisfaction
•Reduced interruptions, especially during
medication passes
•More time with patients
•RN confidence in process
•Cost Avoidance
•Waste reduction
•Explained rationale for change
•Reducing distractions/interruptions
•Made DV voluntary for SQ insulin
•A few continue DV
•Instructed RN in procedure for BCMA
override, documentation
•Observed RN give SQ insulin dose
•Follow-up visits over a month
Process (def.) A series of steps leading to a result
1. Reduce the number of steps in the
process.
2. Increase the reliability of individual
process steps.
Process A
Process B
Process C
Process D
Step 1
99%
99%
99%
99%
Step 2
---
99%
99%
99%
Step 3
---
---
99%
99%
Step 4
---
---
---
99%
99%
98%
97%
96%
Overall Reliability
Forcing Functions
Fixing
Systems
Constraints
Automation
Computerization
Protocols & Order Sets
Double Checks
Rules and Policies
Education
Fixing
People
Total Hours in DV Activity (1.5 - 3” per DV event) 112,516
events
Estimated Interruptions (4:1 ratio med pass :
interruption)
Estimated Clinical Errors Induced by DV (+12.7% risk per)
Annual Cost of DV-Induced Error (1% harmful errors,
$8750 ea)
2812 - 5625
28,129
3772
$330,500
Interruptions during medication pass, self-reported (pre)
95%
Interruptions during medication pass, self-reported (post)
14%
Agree/strongly agree discontinuing DV ↑ patient safety
risk
5%

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