High-Risk Medications,

High-Risk Transfers

Miriam Cardena, Katelyn Hendricks,

Yevheniya Khrobust, & Laurine
Vanlerberg-Maldonado

November 2, 2017
Background
Patient: 47 year-old female
Problem: HX primary pulmonary arterial
hypertension
Admitted: Sepsis secondary to an infected IV line
where she was receiving Treprostinil (potent
pulmonary vasodilator)
High Alert medication DO NOT FLUSH THE LINE
Ordered: New line to be placed by interventional
radiology
Line was flushed in radiology as a result of pump
alarming and trying to find the cause
Result: Patient experienced flash pulmonary edema
and respiratory distress needed emergent
intubation
 Manpower Methods
Finding alarm source

No Training Flushing the IV line

Effect
No Shift report
Not checking line High Alert
medication
was flushed
through an
Medication IV line,
causing a
longer ICU
IV pump Flush stay and a
near code
situation
IV line

Machines Material
Root Cause Analysis
The radiology team was not informed
about the flushing restrictions on
patients IV line, so the patient received
a large does of a potent pulmonary
vasodilator, resulting in emergent
intubation and a longer stay in the ICU.
Actions to prevent further
occurrence
Strong: All lines with high alert
medications will be labelled with a red
tag stating do not flush
Intermediate: The pump delivering high
alert medications will be labelled with
alert do not flush line
Weak: All members of the team will log
into the patients MAR before caring for
patient
Outcome Measures
N= number of IV lines with high alert
medications with proper labeling.
D= Total number of IV lines with high
alert medications.
Threshold = 98% of the IV lines will have
the proper labeling
Date= the IV lines will be monitored for
6 months
Action/ Process Outcome

98 percent of the high alert IV lines will

have the proper labeling by April 2017
70 percent of all other IV lines will be
properly labeled by April 2017
Stakeholder Analysis
Internal (unit) stakeholders
ICU Nurses
Charge nurse
Radiology technician (IR department)
Transport team
Cleaning team
External stakeholders
Pharmacist
Medical staff
 Force Field Analysis
Forces FOR Change Forces AGAINST Change
(Driving Forces) (Restraining Forces)

Patient safety Hospital policy

Quality of care Extra cost for
Hospital stay days protocol
Protocol follow up implementation and
Treatment cost follow up
Management
changes

Strategies to mitigate restraining forces:

In the case study, a new protocol was implemented that requires patients
to be escorted by the charge nurse during transfers from the ICU.
References
AHRQ. (2017). High-risk medications, high-risk
transfers. Retrieved on October 10, 2017 from
https://psnet.ahrq.gov/webmm/case/423/high-risk-me
dications-high-risk-transfers