Safety Story 

 

Brianna Thompson, PharmD, BCPS, BCCCP

UPMC St. Margaret   

  

In her role as the clinical pharmacy specialist in critical care, Brianna Thompson, PharmD, BCPS, BCCCP, improves the delivery of safe patient care every day. In two recent examples of good catches, Brianna reduced potential harm to a patient. While rounding on a COVID-19 unit, she participated in a discussion about managing hyperglycemia in a patient who was also receiving high-dose vitamin C. The initial plan was to start an insulin infusion to address the hyperglycemia, but Brianna reminded the team that Accu-Chek values are inaccurate—artificially high or low—in patients receiving high-dose vitamin C and recommended checking a laboratory-drawn glucose value. In this case, the lab draw value result was significantly lower than the Accu-Chek, and an insulin drip was no longer deemed necessary for the patient. Brianna’s intervention prevented unnecessary medication and potentially resultant unrecognized hypoglycemia; however, she also reported this event to the hospital’s voluntary reporting system to ensure the risk was known systemwide. As a result of Brianna's report of this event, computer changes were put into place systemwide to ensure providers are aware of the potential interference of high-dose vitamin C with Accu-Chek results.

In another recent good catch, Brianna was completing an admission medication history for a patient who was in the process of being admitted to a medical/surgical unit. Brianna noticed the presence of a continuous prostacyclin infusion device (treprostinil) for this patient—which could have put the patient at risk if they were admitted to a med/surg unit lacking the appropriate level of monitoring. Brianna worked with the admitting ED physician and admitting primary service to change the patient’s admission plan and level of care to ensure the patient received the proper level of monitoring should the continuous prostacyclin device malfunction while they were in the hospital. Brianna is one of UPMC St. Margaret’s top reporters of medication events and her reports and interventions make a difference for patients there. The hospital’s pharmacy is proud to have Brianna as an advocate for patient safety.

 

Staff were educated on the new patient education form developed by the Fall Prevention Committee. The patient education form, for newly admitted patients, was designed to assist the nursing staff to enhance a high fall risk patient’s understanding of why the patient is a high fall risk and includes identification of fall risk factors and fall prevention strategies. The team was also educated on the Environmental Assessment form, developed by the Fall Prevention Committee to be completed by staff twice monthly. This tool focuses on the physical environment of the inpatient room and bathroom and ensures that staff is regularly monitoring the room for safety hazards. Staff committed to hold each other accountable to the Fall Prevention Standard of Nursing Practice. As a result of their efforts, 3 South achieved the significant milestone of being fall-free for more than a year and demonstrated their strong commitment to patient safety.

 

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