At Brigham and Women’s Faulkner Hospital, delivering safe, high-quality care is at the center of all we do for our patients and their families. For staff members who exhibit exceptional care in regards to patient safety, the hospital recognizes them with a Patient Safety Award. Two staff members: Bethany Bersani, PharmD, and Marachel (Rachel) Nerier, RN, were recently honored with Patient Safety Awards.
The two were recognize for their excellent collaboration solving a drug monitoring issue and attentiveness to patient safety.
The event, which was reported in Brigham and Women’s Faulkner Hospital’s safety reporting system, RL Solutions, involved a patient who was ordered to start a heparin drip. The Nursing Communication Order written by the provider contained instructions to decrease the heparin rate. This deviated from the RN-Driven Protocol. Nerier was the clinical nurse caring for the patient. She was concerned about how to best proceed and contacted Bersani in the Pharmacy.
Upon further review of the order, Bersani advised Nerier not to decrease the infusion without first speaking to the provider to re-enter the order as a Provider-Driven Protocol or to re-enter the rate as a new Nurse-Driven Order. Bersani recommended this course of action because the Pharmacy does not receive notifications about any specific provider - nursing communications. If Nerier were to follow the instructions as written and deviate from the protocol, there would be no way for the Pharmacy to know Nerier was instructed to follow this order, which would then appear as an administration error.
To resolve the issue, the provider was contacted, and the order was adjusted to the correct rate and format.
“This event reflects a near miss and excellent intervention by Rachel to ‘stop the line’ when it was uncertain how to best proceed with the order due to conflicting order instructions,” says Executive Director of Patient Safety, Quality, Risk, Infection Control, CDI and Clinical Compliance Christi Clark Barney, MSN, RN, “Nursing is encouraged to contact Pharmacy with any questions or concerns regarding heparin infusions. Bethany’s diligence in reporting this event and collaboration with Rachel is a great example of safety culture in action!”
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