Ensuring Patient Safety in In-patient Peritoneal Dialysis · An in-depth evaluation of the PD program at UPMC Shadyside identified multiple potential patient safety issues. A multidisciplinary

Ensuring Patient Safety in In-patient Peritoneal Dialysis

Staci L. Mamula BSN RN CCRNUnit Director, Surgical ICU

UPMC [email protected]

Project Aim

To transform the patient safety paradigm to reduce the risk of harm to a patient receiving continuous ambulatory peritoneal dialysis (CAPD) in the in-patient setting by at least 50% in one year

Multidisciplinary Team MembersDepartment of Nephrology

David Levenson MD

Jose Bernardo MD

Nitin Kamat MD

PharmacyDennis Schilling PharmD

Madalyn Bates RPh

Louise Gillis PharmD

Ann Corpman Pharm D BCPS

Amber O’Malley PharmD

NursingStaci Mamula BSN RN CCRN

Blaney Firestone BSN MHA RN CMSRN

Amber Dickson BSN RN CCRN

Deborah Panos BSN RN CCRN

David Sever MSN RN

Sharon Vlha BSN RN

Amy McLaughlin MSN RN

Nicolette Mininni MEd RN CCRN

Patty Kammerer MA RN

Frontline Nursing

Nephrologists

Pharmacy

Informatics

Supply Chain

Finance

Advanced Practice Nurses

Executive Management

AbstractPeritoneal dialysis (PD) is an attractive option for renal replacement therapy for patients with end stage renal disease. PD offers increased flexibility and freedom for patients to maintain independence and normalcy in their daily lives. Additionally when compared to hemodialysis, PD offers fewer infection related complications, better survival, and significant cost savings (approximately $20,000 per year). For these reasons the number of patients receiving PD is on the rise and hospitals must be prepared to provide this therapy in the acute care setting despite its still relatively low frequency.

An in-depth evaluation of the PD program at UPMC Shadyside identified multiple potential patient safety issues. A multidisciplinary team was formed to systematically address and resolve these safety concerns. Over the last 16 months, significant progress has been made, including the major accomplishments of developing a PD order form that ensures clear and accurate PD prescriptions and transitioning PD from a nursing treatment to a medication treatment, thus allowing the pharmacy to verify, fill, and dispense PD solutions. This improvement alone has led to a 266% risk reduction in PD therapy.

With multiple safety concerns to be addressed, this project has required ongoing focus and cooperation between several departments. Additionally, cooperation has been extended to include UPMC Presbyterian and UPMC East PD programs. While work continues to resolve the few remaining safety concerns and to introduce continuous cycling peritoneal dialysis as a new modality in the Shadyside PD program, there is no doubt that the accomplishments of this team to date have had a major impact on reducing the potential risk of harm for the PD patients in our care.

Quality Indicators

Volume of Peritoneal Dialysis Patients & Days of TherapyClassic CAPD (Nursing Treatment) Baseline Data is manually collected by daily charges only

Failure Mode Effects Analysis Before & After Test of Change

IHI Measurement of “Risk Priority Number”Plan to decrease the number of failure modes (lessen opportunities for failure by decreasing variation in the new process)

Medication Occurrences Reported related to CAPD

Spotlight on PD

Baseline Data

1.4

2.4 2.6

0

0.5

1

1.5

2

2.5

3

Patient Encounters per Month

Peritoneal Dialysis Patient Volume

FY 2010FY 2011FY 2012

5.4

12.1

14.8

0 10 20

Treatment Daysper Month

Peritoneal Dialysis Treatment Volume

FY2012

FY2011

FY2010

Annual increase in both volume of patients treated and number of treatment days, exposing additional patients to potential for harm

Old

Pro

cess

Failure Mode Failure Cause Failure Effects

Likeliness of

Occurrence (1‐10)

Likeliness of going

Undetected (1‐10)

Severity (Potentia

l for Harm) (1‐

10)

Risk Priority Number

Physician orders PD by free text physician to nurse communication order

Communication orders are unformatted as to content

and do not generate scheduled tasks

Free text order can be missed or missing key element

5 6 7 210

Free text order clearly defines number of exchanges per day



6 6 7 252

Free text order clearly defines dianeal fluid for each

exchange



6 6 7 252

Free text order clearly defines dianeal fluid volume for each

exchange



6 6 7 252

Free text order clearly defines dwell time for overnight

exchange



6 6 7 252

Free text order clearly defines medication additives for each

exchange



2 8 9 144

Free text order clearly defines when therapy will begin and

end



6 6 7 252

Free text order is discovered by primary care nurse

Communication orders do not generate scheduled tasks

Free text order can be missed 5 6 7 210

Primary care nurse is familiar with the PD process

Communication orders do not route to dedicated resources

Free text order can be misinterpreted by inexperienced staff

5 6 7 210

Primary care nurse must go to 6 Main storeroom and find

appropriate Dianeal fluid and volume to match free text

order

Communication orders do not route to dedicated resources

Free text order can be misinterpreted by inexperienced staff

10 5 8 400

If Free text order defines medication additive, Primary Care Nurse must enter a pharmacy order on the

patient to get the medication



2 8 9 144

If Free text order defines medication additive, Primary Care Nurse measure and add medication to each exchange

volume in a sub sterile environment



8 5 10 400

Primary care nurse coordinates, measures , instills and drains each

exchange volume as ordered in free text order




5 6 7 210

Physician orders any changes in PD therapy by free text

physician to nurse communication order




5 6 7 210

Physician orders any changes in PD therapy by free text

physician to nurse communication order must

then discontinue any previous free text order




9 8 7 504

Free text orders have no ability to generate patient

charges

Daily PD charges must be manually entered each day of

therapy

PD therapy may not be noted by HUCs to charge on a daily

basis8 8 2 12816 Total

Failure Modes

Total Risk Priority Number: 4,030

New

Pro

cess

12 Total Failure Modes

Total Risk Priority Number: 1,100

Timeline

Outcome Results

4030

11000

500

1000

1500

2000

2500

3000

3500

4000

4500

Risk Priority Number

FMEA Risk Reduction Analysis

Baseline NursingTreatmentNew MedicationOrder Process

266% Improvement

Further risk reduction beyond the ordering process includes:Development of annual nursing PD competencyMore than 60 additional nurses trained to provide PD therapyPD flow sheet redesigned to simplify calculations and eliminate errors in documentation Commercial fluid warmers purchased to warm fluid in less than 20 minutes versus old practices of warming in microwave (risk of hot spots and burns to patient) or using heating pads (took hours to warm, delaying treatment)Pharmacy now responsible for maintaining PD solution inventory, ensuring product availability

Outcome ResultsPreviously, • CAPD Therapy as a Nursing

Treatment • Free Text Unformatted Order• High variation in the volume and

strengths of PD solutions• Any additives ordered for the bags

added by the nurses on the floor

NOW, CAPD as a MedicationStandardized Binary Order FormAdditives made in Sterile Products Area of Pharmacy

BarriersChanging the Culture-Breaking Down Silos-Changing Mental ModelsLack of Communication Between Disciplines

Nursing-Pharmacy-Distribution

How to use the PD charging process to support the additional staffing to provide PD therapy remains undecided Physical space needed to be created in pharmacy to house PD solutions, delaying transition to new processCurrently, order sheets and nursing flow sheet available only on paper through Print on Demand

Development of eRecord order set and nursing documentation awaiting system approval

Last PD policy and procedure update done in 2006PD policy and procedure not currently housed on Infonet

Attempts to coordinate new policy and procedures with sister hospitals has been a lengthy process

Lessons LearnedSet realistic target dates for completion Identify Champions and Experts Early in the ProcessCreate Simple Rules to Accomplish One Goal at a Time

Next Steps

Continue to work with Informatics department to pursue eRecordorder sets and electronic nursing flow sheet documentation

Complete Policy and Procedure revisions and submit for approval

Work with nephrologists to develop nursing education and competency to introduce continuous cycling peritoneal dialysis (CCPD) at Shadyside

This form of PD is more typical of a patients home therapy and will allow patients to continue this therapy while in the hospital

Evaluate readiness to spread nursing competency to additional nursing units

References

Gomez, N. J. (Ed.). (2011) Nephrology Nursing Scope and Standards of Practice, 7th

Edition. New Jersey: American Nephrology Nurses Association.

Li PK, et al. Peritoneal dialysis-related infections recommendations: 2010 update. PeritDial Int 2010; 30, 393-423.

Trissel’s Handbook on Injectable Drugs

http://www.advancedrenaleducation.com/PeritonealDialysis/Complications/PeritonealDialysisRelatedInfections/DiagnosisandTreatmentofPeritonitis

http://emedicine.medscape.com/article/1926162-overview Drugs in Peritoneal Dialysis

Molzahn, A. (Ed.). (2006) Contemporary Nephrology Nursing: Principles and Practice, 2nd Edition. New Jersey: American Nephrology Nurses’ Association.

Ensuring Patient Safety in In-patient Peritoneal Dialysis · An in-depth evaluation of the PD program at UPMC Shadyside identified multiple potential patient safety issues. A multidisciplinary

Documents