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Abstract
Background Failure to reliably use Computerised Physician Order Entry systems for continuous medications increases a patient’s risk of experiencing adverse drug events, is outside the scope of practice for nurses and contradicts regulatory standards.
Objectives Increase the percentage of continuous medications infusing in the Paediatric Intensive Care Unit matching the current order from 74% to 90% by May 31, 2017 to eliminate adverse drug events.
Methods An interdisciplinary team conducted a Failure Modes Effects Analysis to identify failure modes and interventions. A Key Driver Diagram was then created to frame the improvement work. The first Plan-Do-Study-Act cycle ensured ordering providers read back orders on rounds to provide real-time loop closure. A Pareto chart of failures identified vasoactive medications as the largest non-compliant category, leading to another PDSA implementing vasoactive titration order-sets. Rapid cycle testing and feedback allowed the team to address concerns before full implementation.
Results Statistical process control was used for the percentage of continuous medications and vasopressors matching the provider order displayed in separate p-charts. Established rules were used for differentiating special versus common cause variation. 431 baseline observational audits revealed a mean compliance of 74% that increased to 93% after 12 months. Subset analysis of vasoactive medications showed an improvement from 38% to 89% compliance.
Conclusions Ensuring continuous medications have matching provider orders uses proven safety mechanisms, ensures nurses provide care within their scope of practice, and reduces adverse drug events. This project will be spread to the Cardiac ICU and has been used to develop guidelines for medication orders in EPIC.
Pareto: PICU continuous IV medication infusions by class that do not match order 6/5/16–9/27/16
P chart: PICU continuous infusions matching the current order group of 20
P chart: PICU vasoactive medications matching the provider order group of 15