Welcome to the Learning from Defects Meeting.
We want to discuss a particular defect that the team identified,
and that's discontinuation of prophylactic antibiotics.
So to review this problem
we'll use this Learning from Defects Tool
and focus on these main questions:
What happened?
Why did it happen?
How are we going to reduce the chance of it occurring again?
And how do we know that it reduced the risk?
So let's talk about the first question, what happened?
In reviewing the events
and talking to the team we have missed
discontinuing antibiotics with 20 surgical patients
over the last two months.
So I've selected the latest patient to review,
a patient who had a cholecystectomy.
He received his prophylactic antibiotics
within one hour prior to the surgical incision,
but the antibiotic was not discontinued
within 24 hours post-op.
And in fact, the chart says that he got two more doses
before the mistake was caught
and the antibiotics were discontinued.
Now, we all know that that's a problem,
because that could increase the risk
for antibiotic-resistant organisms
and we have seen an increase in readmissions
for post-op infections.
So next is question number two, why did it happen?
I remember Mr. Smith.
He was the elderly man from Florida with lung cancer
who arrived in the unit after a right lobectomy.
We went back and checked and we couldn't find a standing order
from the ICU doctor to stop administering the antibiotics.
So unfortunately, the antibiotics were continued,
even though they weren't needed.
And we have talked before
about the problem of poor communication during handoffs,
so even if there was an order to stop,
it could have been missed.
We could have an automatic stop order
generated from the pharmacy for our post-op patients.
Okay.
So we've just named several contributing factors here.
Number one, no standing discharge physician order;
number two, lack of effective communication
at handoff between the ICU and the floor;
and number three,
no automatic stop order generated in the pharmacy.
So how can we reduce the chances that this will happen again?
We need to flag the steps
in the Surgical Care Improvement Project
or the SCIP protocol and the medical records.
So when we hand off care on the floor,
or if there is a shift change on the floor,
everyone knows when the patient's antibiotic
needs to be stopped.
We can write a protocol or standing order
and get the surgical committee to approve it
so that we have a standing order to stop the antibiotics.
Or we could have a pharmacist do a double check
and monitor the surgical antibiotics
to make sure they're stopped,
or automatically generate a stop order in the pharmacy.
That sounds good! These are some great ideas!
So let's prioritize these.
And how well do we think that this specific intervention
is going to solve the problem
and how likely is it that the intervention
is going to be implemented and executed?
So we'll start with putting flags
in the internal medical record for the SCIP protocol.
So let's have a team discussion and then prioritize this.
Thanks very much team!
That was a great discussion.
So it looks as if our three priority interventions
here are to:
one, develop a standing order for stopping antibiotics
and assign a pharmacist to monitor these.
Two, we can generate
an automatic stop order in the pharmacy.
And three, we'll need to talk a bit more about
improving effective communication at handoff.
So what needs to be done, who is going to be responsible,
and when are we coming back together to follow up?
Well, I'll put my name there beside number one;
standing order for
discontinuation of surgical antibiotics.
I'll talk to my surgeon colleagues
at our next department meeting
and we'll agree to a standing order
that you can take to the surgical committee.
Our next meeting is next Tuesday,
so I'll get back to you by Wednesday.
Okay. And I'll be responsible for identifying a pharmacist
to monitor the antibiotics,
and I'll work with my Pharmacy Director
to automatically generate the stop order in the pharmacy.
I'll need to speak to some of my colleagues as well.
I can get back to you by Wednesday too.
Great!
Well, we have a staff meeting next week
where we can follow up on this conversation.
Thanks everybody! Thank you!
In our last Learning from Defects Meeting we focused on
the issue of stopping prophylactic antibiotics,
and I think you'll all remember that we focused on
two specific interventions to fix this defect.
One was to have a standing order for stopping the antibiotic,
and the second was to assign the pharmacist
to monitor these as a double check.
I want to thank both Chuck and Erica
for taking the lead on these interventions,
and I want to encourage all of you to look at our data.
There are no misses here.
All antibiotics have been stopped appropriately
during the past three weeks.
That's excellent news!
Glad to hear it!