Lakeridge Health Corporation

1

• Lakeridge Health Corporation
• Narcotic (Opioid) Medication Safety Initiative
• Using Process Flow Maps, Root Cause Analysis,
  Workflow Construction Charts, Risk Ranking Scales

2
Team Members

• Patricia Boyd, Registered Nurse, Post Acute
  Specialty Services, Bowmanville Site
• Thom Chambers, Director, Professional Practice
• Annette Down, Leader, Risk Management and Patient
  Safety
• Barb de Rond, Clinical Leader, Pharmacy,
  Bowmanville Site
• Pat Dingman, Clinical Leader, Post Acute
  Specialty Services, Bowmanville Site
• Francis Henke, Clinical Education Leader, Oshawa
  Site
• Denise Lamont, Quality Coordinator of Clinical
  Data for Post Acute Specialty Services Program
• Shelley McKinney, Director, Pharmacy
• Christena Selby, Site Leader, Bowmanville Site
• Beverley Tezak, Leader (Director), Quality,
  Patient Relations and Policy

3
Background

• The overall aim for this project was to reduce
  narcotic medication errors to improve patient
  safety.
• Patient safety concerns related to narcotics
  administration arise due to
• Large selection of narcotic products
• Look alike and sound alike names
• Packaging and labeling
• Infusion pumps and patient controlled analgesia
• Internal challenges (environment)
• Physical space challenges

4
QI Tools

• BETTER Reporting System
• Workflow Construction Charts
• Colour Coded Risk Ranking Scales
• Root Cause Analysis
• Process Flow Mapping

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BETTER Reporting System
6
Workflow Construction Charts
Potential Breakdown in Process
Current Process

• Not done
• Not recorded
• Not reported
• Not accurate

MD or Nurse does Assessment
Harm Reduction
Why

• Education

• Time constraints?
• Forgot to record, distractions
• Education required to report
• accurately

7
Coloured Coded Ranking Scales
High Risk
Low Risk

• High probability for error
• Unsafe to patient
• Unsafe to Staff
• High frequency of the occurrence
• Urgency
• Significant Impact
• Potential for harm
• Quick Win
• Significant system impact

• Low probability for error
• Low impact of the outcome
• Low impact staff and patient
• Infrequency of occurrence Urgency
• Significant Impact
• Potential for harm
• Quick Win
• Significant system impact

High Priority

• Low probability for error
• Low impact of the outcome
• Low impact staff and patient
• Infrequency of occurrence Urgency
• Time consuming, complex process,
• long term planning

• High probability for error
• Unsafe to patient
• Unsafe to Staff
• High Frequency of the occurrence
• Not Urgent
• Wont have significant impact
• Reduced potential for harm
• Time consuming, complex process,
• long term planning

Low Priority
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Root Cause Analysis
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Process Flow Mapping
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Intended or Achieved Outcomes
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Key Success Factors/Enablers

• Teamwork, collaboration and an inter-professional
  approach to assessing narcotic administration.
• Following the implementation of the electronic
  good catch and actual event reporting system
  (BETTER) in June 2007, the number of reported
  medication incidents increased significantly as a
  result of a) education, b) ease of use of the
  system and c) an increased focus on patient
  safety.
• Ongoing monitoring of practices such as the end
  of shift narcotic medication counts, review of
  narcotic records and daily delivery of
  medications by pharmacy technicians resulted in
  early detection of narcotic medication incidents
  and increased frequency of reported of actual or
  potential errors.
• Leadership identified that patient safety is
  paramount and a review of staffing consideration
  and impacts was secondary.

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Potential or Actual Barriers

• Nursing staff initially felt the implementation
  of the independent double check was a punitive
  act that targeted this unit for making and
  reporting narcotic medication errors.
• Resistance to change was overcome through
  leadership excellence in maintaining and
  sustaining gains throughout the year long change
  process.

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Lessons Learned

• sustainability for practice change, leadership
  engagement, and supporting staff throughout the
  process of change were all essential
• engaging staff during change management guides
  greater understanding by providing them with the
  results of literature reviews for best practice,
  including ISMP alerts/bulletins and the safety
  literature
• policy and procedure changes must reflect
  evidence and best practices
• ongoing discussions and meetings with staff kept
  them informed of updates and methods for
  maintaining and sustaining the change.

14
Next Steps

• Nursing Professional Practice has committed to
  changing nursing practice across the organization
  for independent double check for high risk
  medications based on the positive results of this
  initiative.
• Further education rollout to nursing staff on
  changes to the medication administration policies
  and procedures will be ongoing.

15

• Confidence, like art, never comes from having all
  the answers it comes from being open to all of
  the answers
• Earl Gray Stevens
• If we always look back, we lose sight of whats
  ahead
• Justin Sims

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Contact Information

• Pat Dingman,
• Clinical Leader,
• Post Acute Specialty Services,
• Bowmanville Site
• pdingman_at_lakeridgehealth.on.ca
• Denise Lamont,
• Quality Coordinator of Clinical Data
• for Post Acute Specialty Services Program
• dlamont_at_lakeridgehealth.on.ca