Improvement Report: Reducing Harm from Oversedation
Miami Valley Hospital
Dayton, Ohio, USA
Team
Michael Craig, Senior Vice President of Medical Affairs
Tim Collins, Vice President of Quality Management
Deb Fearing, PharmD
Vicky Barnthouse, Director of Nursing
MariBeth Derringer, Director of Quality Management
Aim
Reduce the percentage of patients with an adverse drug event (ADE) from oversedation by 50 percent
Measures
- Percent of ADEs from oversedation, among patients receiving narcotic and sedative agents
- Number of Narcan ampules administered per quarter
- Number of Romazicon ampules administered per quarter
Changes
We found that two medications — Demerol and Phenergan — were contributing the most to our ADEs from oversedation. We used forcing functions to change the availability of these medications.
- Eliminated Demerol as a choice with Patient Controlled Analgesia (PCA) pump. The remaining medication choices provide adequate pain relief and are less likely to cause oversedation.
- Replaced Phenergan 50 mg vials with 25 mg vials to decrease the chances that a nurse would inadvertently administer a higher dose than what was ordered.
Results
 
Summary of Results / Lessons Learned / Next Steps
Once we identified the sources of our ADEs from oversedation, which we attributed primarily to two medications, we knew what changes to make. Using forcing functions to reduce choices eliminated many of the problems we had been having. We continued to monitor the use of Narcan, to watch for occurrences of oversedation ADEs that were not caught during our patient record reviews.
- Listen to members of the front-line staff and consider their perspectives when implementing changes that affect their work. The staff often gave us the reasons why things were occurring so we could fix the causes, not just implement a change.
- Audit and reinforce any new changes to see if they are really working. Monitoring use of Narcan ampules confirmed that less patients were requiring intervention for oversedation.
- Expect that other things happening in your organization may impact your ability to spread improvements to other areas. Our team expected to see the changes spread to other teams working on patient safety, but that didn’t happen due to the impact of issues such as changes in unit management, staffing issues, and patient acuity.
Contact Information
MariBeth Derringer
Director of Quality Management
mcderringer@mvh.org
| 
