I AM Patient Safety 2022 Safety Story Award

2022 IAPS Safety Story Award Winner Registered Nurses on 5 Cathcart/Schiedt (Medical-Surgical Unit) Penn Medicine  

Registered Nurses on 5 Cathcart/Schiedt (Medical-Surgical Unit)
Pennsylvania Hospital

A number of patients throughout the hospital receive liquid PO methadone as part of their ongoing opioid use disorder treatment, and 5 Cathcart/Schiedt cares for a large majority of them. Each patient may have different medication dosing in terms of number of milligrams and doses per day. The process for dispensing the syringes involved a pharmacy tech coming to the floor during their rounding times and handing the syringe to a registered nurse (RN). There were times when the RN caring for the patient was not available, and another RN had to take the syringe. There were times where the patient was not ready for the medication or was sleeping, and the RN had to hold onto it until the patient was ready or send it back to the pharmacy with the tech, only to need it an hour later.

The number of patients requiring methadone has increased over this past year as Pennsylvania Hospital has seen a sharp increase in patients requiring treatment for opioid use disorder. At the daily safety huddle, the RNs on this unit started mentioning their concerns about the possible lack of safety and security involved in the dispensing of methadone from pharmacy to the unit. They also reported this concern as a potentially unsafe situation in the hospital’s safety event reporting system. The unit educator and manager heard these concerns and reached out to the pharmacy to discuss the concerns of the RN staff. The pharmacist came to the unit’s staff meeting and proposed a change to the dispensing of oral liquid methadone where it would be housed in a drawer of the unit-based medication dispensing machine.

A change like this on one unit requires the change to occur on all units of the hospital, so the proposal was presented to the nursing education department, the unit managers, the medication diversion task force, the medication safety committee, and executive leadership. There was unanimous approval to move forward with this change. Education huddles were created, education was disseminated at staff meetings and safety huddles, and the new process went live without any problems. There was some initial increase in the number of discrepancies created with the countback of milligrams of methadone remaining in the drawer when a syringe was removed; reinforcement of the initial education remedied that swiftly. The staff have since reported great satisfaction in having a secure place to store the methadone, the ability to remove it when the patient is ready for it, and the ability for accurate tracking of syringe removal and wasting as with other controlled substances on the unit. This was an excellent example of staff speaking up, leadership bringing their concerns forward, and the creation of safer practices moving forward.

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