Kaizen Committee

Minutes
PAGE 1 OF 4
Purpose: The purpose of the Kaizen Committee is to provide amazing service by enhancing patient care and safety
through improvement of the medication management system.
Date: May 12, 2014
Present: Staci Aden, Pam Belleau, Heidi Bougher, Veronica Cantrell, Valerie Christenson, Angie Dangler, Shannon Davis,
Kirby DiBerardino, Krystle Fulton, Ann Heisler, Deb Herrera, Jessica Hopkins, John Karels, Nicole Kirchner,
Terri LaLier, Meg Mahaney, Amy Malcom, Sondra May, Angela Miskolci, Heather Morris, Tammy Negomir,
Alan Oldland, Sylvia Park, Holly Phillips, Stacy Rodriguez, Lee Rucker, Gretchen Seibold, Terry Shade, Galia
Spychalska, Chris Steckline, Denise Street,
Time: 0700 0800
Absent: Location: AOP 2005
Guest(s): Aurora Davis, Danielle Rhyne, Courtney Shakowski Co-Chairs: Staci Aden & Angie Dangler
Next Scheduled Meeting: July 14, 2014 Recorder: Staci Aden & Angie Dangler

AGENDA ITEM ISSUES ACTIONS
RELATIONSHIP TO
MAGNET COMPONENTS
Minutes from April meeting Minutes from Aprils meeting were approved.

New members were introduced and welcomed: Nicole Kirchner
(8E Rehab), Amy Malcom (11
th
floor Oncology), Galia Spychalska
(ED), Meg Mahaney (Neuro ICU).

Updates
MDVs audit results



MiniBag+ diluent chart



25 ml NS bag availability




Angie Dangler shared audit results for
individual units.


Angie Dangler distributed an updated
MiniBag+ diluent chart.


Angie Dangler provided an update as to
when the 25 ml NS diluent bags will be
available for order.


Goal compliance is 90%; average compliance for Mays audits
was 94%. Members who did not complete their audit were
reminded to please do so for the next meeting.

Members were asked to replace any outdated diluent charts with
the most recent one. The chart is also available on the HUB and
Pharmacy Department webpage.

Central Supply is hopeful that the diluent bags will be available by
the end of May or early June. Angie will continue to provide
updates and notify staff once the diluent bags are available.


Empirical Quality Results



Structural Empowerment



Exemplary Professional
Practice


PAGE 2 OF 4
AGENDA ITEM ISSUES ACTIONS
RELATIONSHIP TO
MAGNET COMPONENTS

Medication Management
Operations policy



Angie Dangler informed members of
changes to the time-critical medication
list since the policy was presented at
Kaizen last month.
The antiarrhythmics dofetilide and sotalol were added to the list.
Previously listed anticoagulants were removed. The pulmonary
hypertension medications were defined to include intravenous
and inhaled formulations.

Structural Empowerment
Kaizen co-chair nominations Staci Aden & Angie Dangler discussed
co-chair nominations
Staci Aden announced her nursing co-chair term is ending, and it
is time to elect a new co-chair. Per the Kaizen Charter the
committee members will elect the nurse co-chair in July of even
numbered years to serve a two-year minimum term beginning in
August of the election year. Nomination slips were handed out
and nominations encouraged; members can nominate
themselves. Members can also email Angie Dangler or Staci
Aden to nominate a co-chair if they were absent at Mays
meeting. Nominees will receive an email asking if they will accept
the nomination, and voting will be done at the July meeting.
Structural Empowerment
IV amiodarone loading dose Pharmacist Courtney Shakowski
presented the addition of IV amiodarone
premix bags for bolus / loading doses.
Courtney informed members that IV amiodarone premix infusion
bags 150 mg /100 mL will replace amiodarone vials in Pyxis.
These premix bags will be used for the bolus dose and will be
administered via the Alaris Smart Pump. The anticipated go-live
date is June 2
nd
with the next Alaris library update. Amiodarone IV
vials will still be available in CODE carts for use in CODE
situations. Courtney will work with Angie Dangler to compose an
email for all staff once the premix bags are available and
Epic/Alaris updates have been done.
New Knowledge,
Innovations, Improvements

WCC additions to IV Administration
Tables
Angie Dangler presented changes to the
IV Administration Tables that were
requested by WCC and approved by
pharmacy leadership.
The WCC requested to have their unit added as an approved
nursing skills category to administer IV digoxin for the treatment of
fetal tachyarrhythmia. They also requested to limit insulin
infusions to WCC only, instead of nursing skills category D that
includes WCC and Birth Center.
Structural Empowerment
Patients Own Medication policy Holly Phillips discussed updates to the
Patients Own Medication policy (POM)
Holly highlighted the changes made to the POM policy. Pharmacy
will now be responsible for verifying any patients own
medications (POM). Pharmacy will not verify POM until the
pharmacist has the product in hand. The RN is responsible for
physically getting the medication to the pharmacy. POM cannot
be tubed. RNs can have their Clinical Pharmacy Specialist (floor
pharmacist) verify if available. If the Clinical Pharmacy Specialist
is unavailable, the RN will be responsible for bringing POM to the
Central Pharmacy for verification. POM will not be barcoded at
this time. The POM consent form will no longer be used. Storage
Exemplary Professional
Practice

PAGE 3 OF 4
AGENDA ITEM ISSUES ACTIONS
RELATIONSHIP TO
MAGNET COMPONENTS
for POM will not change from the previous process. Pharmacy
will only verify POM that are in their original prescription bottles.
PCA policy Aurora Davis discussed updates to the
PCA policy.
Aurora highlighted changes made to the PCA policy. The policy
was updated to include use of standardized PCA medication
concentrations, Alaris PCA pumps, and palliative care order sets.
Pain and sedation scales referenced in the policy were also
updated to reflect current practice. In addition, the reference to
pediatrics patients was removed. Members provided feedback
about suggestions about the definition of pediatrics in terms of
age and weight. Members approved the policy edits.
Exemplary Professional
Practice

Alaris
Pumps leaving hospital









Alaris Multidisciplinary
Committee membership

Sylvia Park discussed the issue of Alaris
pumps leaving the hospital without
approval.








Sylvia discussed that the Alaris
Multidisciplinary Committee is trying to
recruit a representative from each unit to
be active on this committee.



Sylvia reminded members that Alaris pumps should not leave the
hospital without approval of either the Alaris Team or Central
Supply. Now that pumps have GPS tracking devices on them,
they are being monitored, so please have approval before
removing from the hospital, even for training purposes. As a
reminder, pumps should not leave the hospital attached to
patients. If patients are transferred, the facility or transferring
company must provide equipment.


Sylvia discussed that Professional Resources took Alaris pump
training out of new hire orientation. The Alaris Committee would
like to have a representative from each unit to assist with unit
based Alaris pump training for new staff. Alaris is also in the
process of potentially integrating with Epic next year and reps will
be needed for training purposes. The following units do not
currently have representation on the Alaris Committee:
SICU, CICU, WCC, Birth Center, 6E Surgery, 8W Ortho, 8E
Rehab, 9 Pulmonary, 12
th
floor ACE, ED, THRU, SSU, CV
Pre/Post, CPCU. Please reach out to your staff to see if anyone
is interested if your unit does not have an Alaris representative.

New Knowledge,
Innovations, Improvements








Structural Empowerment
Medication Safety
Wrong Patient Errors







Sondra May presented data related to
wrong patient errors for the time period
March 2013-February 2014.





There were 52 wrong patient errors reported for the selected 12
month time period; 50% of these errors were near misses and
50% reached the patient. Twenty of the wrong patient errors
occurred in the retail setting. Sondra encouraged members to
reinforce to staff the importance of using two patient identifiers,
bar code scanning, five rights, and medication show and tell (in
the retail setting).

Empirical Outcomes






PAGE 4 OF 4
AGENDA ITEM ISSUES ACTIONS
RELATIONSHIP TO
MAGNET COMPONENTS

Incompatibility errors








Right way to report SI events

Sondra May presented data related to
incompatibility errors for 2013.







Sondra May discussed the importance
of correctly reporting Safety Intelligence
(SI) events.

Sondra explained that CMS and Joint Commission require UCH
to report incompatibility errors annually. There were 10 drug
incompatibility events reported in 2013. Sondra provided
members a tip sheet that is available on the hub illustrating how to
check IV compatibility through Micromedex. Members were
reminded that if a compatibility result of not tested is returned
from a query, the medications should NOT be run together.

Sondra provided print outs of the most recent Pharmacy Update
where an article highlighted the difference between Unsafe
Conditions and a Patient event when reporting a medication
error in Safety Intelligence. If a patient is involved with a
medication error, staff should report it as a Patient event.
Unsafe Conditions should be used for errors that relate to an
environment factor, not a specific patient.

Empirical Outcomes







New Knowledge,
Innovations, Improvements
Pyxis
Pyxis software upgrades




Oral cytotoxic medication
warning

Shannon Davis informed members that
all Pyxis machines have been upgraded.



Shannon discussed that the Pyxis will
display a cytotoxic warning message on
removal of oral cytotoxic medications.

Shannon highlighted the upgrade completed on all Pyxis
machines. The Bio ID performance has been fixed, the reboot
function should be quicker, and the cubies should have enhanced
performance.

Shannon discussed that now Pyxis will display a cytotoxic
medication warning when removing oral cytotoxic medications.
The warning states: Caution Cytotoxic: Handle and dispose per
chemotherapy policy. Sondra May reminded members that the
MAR Admin note should be looked at closely as well for this
information. The medications attached to the Pyxis warning were
taken from those medications listed in the oral cytotoxic/chemo
policy. There is a possibility that there are other cytotoxic
medications on formulary that are not in this policy, and thus will
not have the cytotoxic warning display upon Pyxis removal. If you
find any oral cytotoxic medications that do not have this message,
please alert Shannon Davis.

New Knowledge,
Innovations, Improvements



New Knowledge,
Innovations, Improvements