Drug Topics - October 22, 2007 - (Page H14)

14HSE DRUG TOPICS OCTOBER 22, 2007 Professional Practice Though a “continuous infusion drip guide” is written on index cards in all ICU patients’ rooms, the state discovered that the ICU lacked a formal policy on continuous infusion of IV medications. After Cruz’s death, the hospital developed a policy requiring narcotics, benzodiazepines, propofol, and all paralytic agents administered by continuous drips to be removed from the pump and the patient’s room when they are discontinued. Cruz’s death also prompted SIUH to revise its guidelines for the weaning of patients from mechanical ventilation and the extubation of intubated patients. The hospital also implemented walking rounds during the change of shift in the ICU and no longer allows nurses to take breaks during shift overlaps. DT State orders policy changes at hospital A fter conducting an investigation into the death of Jason Cruz, the New York State Department of Health ordered Staten Island University Hospital to implement policy and procedural changes to prevent deadly medical errors. The hospital’s “Plan of Correction” includes: •The creation of a Patient Safety Council. The council is required to evaluate patient safety practices and provide reports to the North Shore/Long Island Jewish Health System board and medical executive committee on a quarterly basis (or more frequently as needed). •A three-month audit of IV pumps (on all discontinued drips) to ensure they are removed from the room. •Observing responses to critical care alarms and determining the “clinical appropriateness” of the response. The hospital was required to conduct 30 observations per month for three months and report its findings to the Patient Safety Council and a hospital Performance Improvement Control Group (PICG). •Reviewing its weaning and extubation policy with nurses, respiratory care workers, and residents at regular staff meetings and with the medical team at quarterly meetings. •Conducting a random, three-month concurrent medical record review on 10% of adult patients that are extubated. The findings of this review must be shared with staff and reported to PICG. •Meeting with hospice to discuss and determine whether alternative safety technology is available to lock IV pumps to prevent unauthorized use and explore the possibility of identifying practitioners making infusion changes. •Counseling the doctor involved (in Cruz’s treatment) about the lack of documentation in the patient’s health record. The Chief Medical Officer must now review the documentation requirements (patient assessment, changes in status, recording test results) at quarterly medical/dental staff meetings. •Conducting a random open chart review of 30 records per month for seven months. •Reviewing hard and soft limits/parameters in the drug library. •Reviewing the policy and procedures for standardized continuous infusion.

Table of Contents Feed for the Digital Edition of Drug Topics - October 22, 2007

Drug Topics - October 22, 2007 Contents Latebreakers Legislative Victory Builds Momentum for Pharmacy Month Letters Health-System Edition R.Ph.s Brace for Payment Denial for Hospital-Acquired Conditions Topical Human Thrombin Helps Arrest Bleeding FDA Panels Fail to Set Target Levels for Renal Patients’ Hemoglobin Warning Letters Raise Patient Safety Concerns for Fentora Ending/Reversing Weight Gain Man Given Fatal Drug Overdose at Staten Island Hospital Pharmacists Playing More Important Role in Dialysis Treatment AHA President R.Ph.'s Here's How You Can Increase Your Value Premier Launches Comprehensive Quality Improvement Project FDA Approves Dexrazoxane for Treatment of Extravasation New Federal, State Reforms to Ease Disaster Relief Kinks 150 Years of American Pharmacy Ten Tips for MTM Success Independent Superstars: The Ones to Watch The New Dynamic Duo A Parkinson's Disease Primer Classified New Products Advertisers Index Viewpoint

Drug Topics - October 22, 2007

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