EP9EO

 

Interprofessional Care EP9EO

 

Using the required empirical outcomes (EO) presentation format, provide one example of an education activity led or co-led by a nurses(s) (exclusive of the CNO) for an interprofessional team which led to an improved patient outcome.

 

 

Example: Nurse-Led Heparin Education Activity Results in Decreased Medication Errors

Problem:
There was an increase in Catholic Health Initiatives (CHI) St. Vincent Hot Springs (SVHS) monthly medication error rate related to heparin infusions.

 

Pre-Intervention

In August 2023, Magen Schaub, BSN, RN, Nurse Manager, 2E Cardiology (2E), noticed an increase in medication errors related to heparin infusions. Beginning in May 2023, the medication administration record (MAR) in the electronic medical record (EMR) calculated the heparin infusion rate as units per kilogram (kg) per hour (hr). Nurses on 2E were used to the units/hr rate, based on the previous protocol.

 

Schaub received incident reports from the Iris event reporting system and feedback from clinical nurses during leader rounding of issues involving the new process for weight-based heparin infusions. Other units were having similar issues regarding heparin infusions, resulting in medication errors for inpatients throughout the organization.

 

The CHI SVHS inpatient medication error rate related to heparin infusions was 3.25 in August 2023. The monthly medication error rate was calculated by taking the number of heparin infusion medication errors for inpatients, divided by the number of inpatients on a heparin infusion at CHI SVHS, multiplied by 100.

 

Schaub collaborated with clinical nurses, nurse supervisors, a clinical nurse educator, pharmacy leaders, and other nurse managers to lead a heparin infusion work group. Delana Lambert, MNSc, RN, ACNS-BC, Clinical Nurse Educator, co-led the group.

 

The group discussed how education was needed for clinical nurses and pharmacists for the new weight-based heparin infusion rate change. The group determined that superusers were needed to provide education and validate the competency of all clinical nurses and pharmacists responsible for heparin infusions.

 

Goal Statement

Decrease CHI SVHS inpatient medication error rate related to heparin infusions.

 

Participants

 

Heparin Infusion Work Group
Name/Credentials	Discipline	Title/Role	Department
Kaitlyn Atkins, MSN, RN, CPN	Nursing	Clinical Director of Nursing	Nursing Administration
DeLana Lambert, MNSc, RN, ACNS-BC	Nursing	Clinical Nurse Educator, Co-Lead	Clinical Education
Magen Schaub, BSN, RN	Nursing	Nurse Manager, Lead	2E Cardiology
Angie Pike, MSN, RN, CMSRN	Nursing	Nurse Manager, Superuser	2W Oncology/ Renal
Sheila Clemons, BSN, RN	Nursing	Nurse Manager, Superuser	Medical Intensive Care Unit
Trish Nicholas, BSN, RN	Nursing	Nurse Manager, Superuser	Surgical Intensive Care Unit
Tanner Ross, BSN, RN	Nursing	Nurse Manager, Superuser	Emergency Department
Mike Long, BSN, RN, CNML	Nursing	Nurse Manager, Superuser	Cardiac Catheterization Lab/Interventional Radiology/Cath Lab Recovery/Cardiac Rehabilitation/ Heart Center Administration/ Diabetes Center
Delia de los Reyes, BSN, RN	Nursing	Nurse Manager, Superuser	4E Medical/ Surgical
Richard Pope, MSN, RN	Nursing	Nurse Manager, Superuser	4W Medical/Surgical/ Pediatrics
Barbara Ellis-Erby, MSN, RN	Nursing	Nurse Manager, Superuser	5E Orthopedics/ Neurosurgery
Phillip Petty, BS, RN	Nursing	Nurse Supervisor, Superuser	Float Pool/Staffing Office
Teresa Moore, BSN, RN	Nursing	Nurse Supervisor, Superuser	2E Cardiology
Jessica Bray, BSN, RN	Nursing	Nurse Supervisor, Superuser	2E Cardiology
Chae Brewer, MSN, RN	Nursing	Nurse Supervisor, Superuser	2W Oncology/ Renal
Laura McConnell, MSN, RN, CMSRN	Nursing	Patient Care Coordinator, Superuser	2W Oncology/ Renal
Chris Cates, RN	Nursing	Patient Care Coordinator, Superuser	2W Oncology/ Renal
Sarah Ostrem, BSN, RN, CMSRN	Nursing	Patient Care Coordinator, Superuser	5E Orthopedics/ Neurosurgery
Brent Overby, BSN, RN	Nursing	Patient Care Coordinator, Superuser	5E Orthopedics/ Neurosurgery
Spencer Burris, RN	Nursing	Patient Care Coordinator, Superuser	5E Orthopedics/ Neurosurgery
Jaydon Peterson, MSN, RN, CMSRN	Nursing	Patient Care Coordinator, Superuser	4E Medical/ Surgical
Tiffany McCain, PharmD	Pharmacy	Director of Pharmacy	Pharmacy
Christi Amerson, PharmD	Pharmacy	Manager of Pharmacy, Superuser	Pharmacy

 

Description of the Intervention

September 2023

• Schaub and Lambert met with Tiffany McCain, PharmD, Director of Pharmacy, and Christi Amerson, PharmD, Manager of Pharmacy, to develop education for clinical nurses and pharmacists. Education included the rationale for the change: the weight-based, nurse-driven protocol achieves faster anticoagulation. In addition, step-by-step instructions for heparin infusions were reviewed. The education activity would conclude with competency validation on infusion rates for the clinical nurses.
• Eighteen nurse and one pharmacist superusers attended an education session led by Schaub and Lambert to ensure competency before checking off other clinical nurses. Objectives of the educational activity included:
  • Explain the rationale behind the change in the delivery of infused heparin and the nurse-driven heparin protocol.
  • Electronically locate or access the nurse-driven heparin protocol within the EMR.
  • Demonstrate how to set up a heparin infusion for a sample patient on an IV pump.
• Once the superusers completed their education and competency validation, they held 30-minute mandatory education sessions for clinical nurses and pharmacists. Nurses and pharmacists were notified of the education during daily safety huddles and flyers posted on each unit. Twelve sessions were offered and included the same objectives and content as the superuser education sessions. Every clinical nurse at CHI SVHS who administers heparin infusions was required to attend an education session.
• Superusers provided education to all pharmacists on the new process for weight-based heparin infusions. Pharmacists attended the same sessions as nurses.

 

The education interventions were fully implemented by the end of September 2023.

 

At CHI SVHS, a nurse manager and clinical nurse educator co-led a heparin infusion-focused educational activity for an interprofessional team that resulted in decreased medication error rates related to heparin infusions for inpatients.

 

References:

Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal of Caring Sciences, 32(3), 1038–1046. https://doi.org/10.1111/scs.12546

 

Schurr, J. W., Stevens, C. A., Bane, A., Luppi, C., Culbreth, S. E., Miller, A. L., Connors, J. M., & Sylvester, K. W. (2017). Description and evaluation of the implementation of a weight-based, nurse-driven heparin nomogram in a tertiary academic medical center. Clinical and Applied Thrombosis/Hemostasis, 24(2), 248–253. https://doi.org/10.1177/1076029617721009

 

Outcome

• (Evidence EP9EO-1, CHI SVHS Inpatient Medication Error Rate Related to Heparin Infusions Graph)