1 1 1 Crafting safe, clear Pre-Printed Orders BC Orthopaedic Collaborative Janice Munroe FH Medication Safety Coordinator September 9, 2008
111
Crafting safe, clear Pre-Printed OrdersBC Orthopaedic Collaborative
Janice MunroeFH Medication Safety CoordinatorSeptember 9, 2008
222
Crafting safe, clear Pre-Printed Orders
BC Orthopaedic Collaborative
Valerie MacDonald FH CNS Ortho/ SurgeryJanice Munroe FH Medication Safety CoordinatorSeptember 9, 2008
333
Implications for practice
DVT prophylaxisPain Management
444
Lessons learned
KISS. It’s 0400 and I have a cold.
Balance flexible options with clarity.
Evidence emerges: Prepare to change.
555
666
DVT Prophylaxis
DALTEPARIN 2500 units subcutaneously at ______ (6 hours Post-op from Admission to Recovery Room
DALTEPARIN 5000 units subcutaneously daily starting Post-op Day 1 x __________ days
Other _______________________________ When giving LMWH, wait 22 hours before removing an epidural or regional catheter. Do not give LMWH for 2 hours after removal.
Pneumatic calf compression devices to each leg to start in recovery room.
777
Pain Management
ACETAMINOPHENCELECOXIB 200 mg po q 12 h post operative day 1 only then CELECOXIB 200 mg po OD x 2 days No Additional NSAIDSOXYCODONE 5-10 mg po q4h prn OXYCODONE SR 10 mg po q12h starting postoperative day 1x 3 days. May increase SR dose to 20 mg the next morning, if breakthrough dosing equals 20 mgs or more. Inform pharmacy if dose increased. Use only if patient is unable to tolerate oral analgesic:
HYDROmorphone sc Or IV
OTHER ___________________________
888
Side effect management
N & VondansetrondimenhyDRINATEproCHLORperazine
PRURITUSdiphenhydrAMINE 25 mg PO or 25 mg IV q4h PRN
SLEEP ZOPLICONE. Or Use patient’s own hssedation.
999
Constipation
LACTULOSE 10 g (15 mL) PO daily - hold if loose stools or diabeticSENNOSIDES 12 mg TAB - 2 TABS PO at bedtime (hold if bowel movement in last 24 hours)GLYCERIN suppository per rectum on post-op Day 3 PRNIf no BM after suppository, give SODIUM PHOSPHATES 130 mL enema per rectum. May repeat x 1
If no BM after enema, call physician
10
Does this look familiar?
Legibly?Really?
Can you read this?
Where do you begin?
14
How safe are Pre-Printed Orders?
Clarity – interpretation of handwriting
Accuracy – order setsEntryVerification
Protocols – support quality care, best practice
Speed – less time to write, enter & verifyKey principles need to be fulfilled
15
What are these key principles?
ContentConsistent layoutClear numerals (trailing & leading zeros)Eliminate lines (decimal points)Consistent units (SI values, mg, Units etc)Tall Man lettering (if in use)Limit use of abbreviations (medication names & ISMP list)
17
vinBLAStinevinCRIStine
cefoTAXimecefUROXime
clomiPHENEclomiPRAMINE
quinINEquinIDINE
18
Protocols – support quality care, best practice
VTE PreventionComplex therapyHigh risk medications
Multimodal Pain ManagementComplex therapyHigh risk medications
19
Fraser Health Pre-Printed Medication Order Guidelines
Developed by the FH Medication Safety Committee in 2007Site level approval processRegional approval process- underwayVersion control
Form ImprintForms on demandEliminates the “addressograph”!
20
Best PracticeMedication Reconciliation
Peace Arch Hospital – FH Pilot siteProcessForms
Reconciliation on admissionEmergencySurgery – Pre-Admission Clinic
Completed day of surgery
History doubles as post-op orders
Surgeon’s therapeutic plan
22
Med Rec & SurgeryThe odd couple?
Why is this a “natural” fit?Med rec involves collecting information regarding medication use PRIOR to admission to hospitalSurgeon may not be aware of the medications or familiar with how they are usedOmissions and unintentional dosage changes can occurComplete documentation (& ordering) of home medications decreases calls to surgeon
23
Med Rec & SurgeryThe odd couple?
Pre-admission Clinic typically collects this medication information
Ideal environmentPatient can bring in medicationsFamily/caregiver may be present to assist
Surgical Daycare Opportunity to identify any changes since PACDocumentation of time of last dose
24
Med Rec & SurgeryThe perfect couple!
Natural fitDocumentation of patient information
Needed prior to surgeryNeeded to provide safe care post-opEnsures medication consistency is maintained throughout hospital stay On discharge, patient returns to pre-admission medications (if still indicated)
25
FH Next Steps
Med Rec will be incorporated into the FH Orthopaedic Improvement InitiativeBurnaby Hospital - first pilot site
September 2008
The remaining 10 FH sites - ??
26