Patient Safety Action Group (PSAG) Newsletter ... - Hartford Hospital!

Patient Safety
Action Group
May 9, 2013
Year 6; No. 19
From the Graduate RN Residency Group:
Do you know SNADD?
Proper narcotic
administration,
documentation and
disposal is critical.
The following is provided by the
Graduate RN Residency Performance
Improvement Group (Christina Camp,
Brittany Menta, Magdalys Ortiz,
Rebecca McDonald, Sara Hills, and
Shoushounova Dallas. )
Do you know SNADD? It is an acronym
for Safe Narcotic Administration,
Documentation, and Disposal.
Patient safety comes first, especially
when it comes to medication
administration.
When administering narcotics,
adherence to the Medication Orders
and Administration Policy and
Automated Dispensing Device (Pyxis)
policy is mandatory. These policies
are easily found on Alfresco.
Key Concepts in Narcotic Administration:
• All medication removal and
administration must match patient’s
orders and electronic medication
administration record (EMAR).
• Medication is to be administered
within 30 minutes of withdrawal
from Pyxis.
• Two nurses are required to
document waste of a controlled
drug. The wasted medication is
to be documented at the time the
medication is wasted (within 30
minutes of removal)
• Controlled substances should be
wasted in the following manner:
tablets should be crushed; capsules
emptied; transdermal patches folded
and cut up; and vials emptied and
expressed. All should be disposed
of in the approved hazardous waste
containers.
• Lost medications require a Quantros
Report, notification to pharmacy and
to the nurse manager.
• Controlled substance keys must be
with RN at all times (IOL)
Following these key concepts
will maintain patient safety and
compliance for all mandated state and
federal regulations.
Remember SNADD for best practice.
The safety of our patients depends on
you.
Voices of
Our Patients
Before my wife was
moved to Palliative
Care, she was a
patient in the main
part of the hospital
where she was being
treated for breast
cancer.
I recall one day near
the end when I came
to visit her, and as I
was leaving, a nurse
saw me. She reached
out and gave me a
hug of compassion
and caring.
That simple act of
kindness has stayed
with me all these
years. I wish I could
find that nurse and
thank her. At the time
I was too choked up
with emotion to say
anything.
Anonymous
Reprinted with permission

Patient Safety Action Group
Page 2 May 9, 2013
Team of the Year Nominee:
TEG Implementation Team
In 2010, we
acquired two TEG
analyzers to use
in the OR. The
TEG analyzer
provides doctors
with immediate
feedback
regarding
patients’ blood
clotting status.
This is especially
critical right after
removal from the
heart-lung machine, when the patient
is most prone to bleeding. (TEG stands
for (Thromboelastograph.)
Minimizing transfusions is safest
for our patients. The use of TEG data
allows for the absolute minimum
amount of blood product to be given.
It was determined that the
Hematology Laboratory would be
better suited to perform TEG testing,
and a team was identified to begin
plans for implementation. This was
a coordinated effort between CLP
Lab staff, hematopathologists,
anesthesiology, perfusion and IT
staff at both CLP and HH.
TEG testing started for cardiovascular
surgery cases. Every time a TEG test is
performed, there needs to be closely
coordinated communication between
the OR and the lab staff because some
TEG samples must be tested within
four minutes of collection.
A call is initiated to alert the lab that
a TEG specimen is being drawn, the
OR runners are in position to deliver
it immediately to the Hematology Lab,
and the lab technologist has entered
basic demographic information in
preparation for the sample.
Prior to implementation of TEG
testing, blood product utilization at
Hartford Hospital was monitored for
appropriateness in the OR, but less
sensitive tests were used to assess
need for blood products.
Data collected since TEG testing began
in July 2011 shows a 27.5% decrease
in blood product utilization, with
annualized savings of approximately
$300,000 to date.
We have improved patient safety,
revised best practices in the OR
using the TEG results, and provided
cost savings to Hartford Hospital, all
while promoting positive interactions
between departments.
Team members: Mike Acosta, Paul
Altonji, Jennifer Bissonnette, Jordan
Blinder, William Campeau, Allison
Conelius, Denzil Copeland, Tina Dibble,
Manny Escobar, Linda Freeman-Bosco,
John Gary, Marbelia Gonzalez, Geoffrey
Hayward, David Hull, Ken Jeleniowski,
Thomas Martin, Thomas May, Leah
Meisterling, Thomas Mort, Alberto
Nieves, Rabi Panigrahi, Tim Phair, Enzo
Pistritto, Birgit Randazzo, John Ravi,
Ruben Rodriguez, Peter Shen, Bradford
Sherburne, Jaime Spafford, Sengaroune
Sundara, Sara Therrien, Nicole Tomasello,
Witold Waberski.
We want to hear from
you. Just email us at
psag@harthosp.org
with your thoughts. If
you do not have access
to e-mail, you can
send your comments
or suggestions via the
inter-hospital mail.
Address the envelope
to the Patient Safety
Action Group. (Please
include your name
and department if you
would like a response
from PSAG.) Useful
ideas win awards!
PSAG Meeting
Location Reminder
Monday, 5/13/13
Special Dining Room
Tuesday, 5/14/13
JB-116
Wednesday, 5/15/13
Special Dining Room
All meetings start at 7:30 a.m.
All staff welcome to attend