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Inpatient Cardiac Units: Developing a Multidisciplinary Approach to Safe and Consistent IV Prostacyclin Management

A. Banworth

Cynthia Bauer

J. Caprio

Keane Catain

Judy Idzi

J. Watts


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Conference: 2011 PH Professional Network Symposium

Release Date: 09.22.2011

Presentation Type: Abstracts

A. Banworth, AARN; C. Bauer, BSN, MS; J. Caprio, BS, RN; K. Catain, BSN; J. Idzi, BSN; T. Ryan, BSN; J. Watts, BSN
University of Maryland Medical Center, Baltimore, MD

PURPOSE: As the designated inpatient units to provide care to Pulmonary Hypertension patients, the purpose of this project was to develop a multidisciplinary approach to safe and consistent intravenous prostacyclin management throughout our healthcare system.

BACKGROUND: Patients diagnosed with advanced pulmonary hypertension have been successfully managed with continuous prostacyclin infusions on an outpatient basis that requires the patient to manage the use of those complex drugs and the associated drug delivery equipment on a continuous basis. When these patients require hospitalization, the responsibility of their drug management shifts from the patient to the hospital medical, pharmacy and nursing staff and places them at risk for medication errors (Kingman, 2010). PH centers have reported medication errors to be common during the use of prostacyclin infusions. Many of these errors have minimal or no effect on the patient (Chest, 2009). Twenty eight of those reported errors led to serious adverse patient events, including 9 deaths, prompting researchers to further investigate (Kingman, 2010). These findings of errors related to prostacyclin infusions seemed to hold true at our organization as well. A review of incident reports at our own center revealed medication errors specific to IV prostacyclin administration related to:

  1. Faulty administration techniques
  2. Knowledge deficit of accurate order entry by physician
  3. Weak handoff with RN to RN at shift change
  4. Weak medication handoff with pharmacy to RN
  5. Staff lack of knowledge about patient travel, backup drugs and equipment

IMPLEMENTATION: Our center is located within a 750 bed teaching facility in a major metropolitan city. Our units primarily care for patients with medical cardiac diseases but began to care for those with pulmonary hypertension about 3 years ago. In response to our own incidents and medication errors (fortunately, none that have resulted in adverse patient effects), a nurse-lead multidisciplinary team agreed to meet monthly to review any previous IV prostacyclin administration issues and develop resources and guidelines for practice. Additional ad hoc members to the group included pulmonary hypertension clinic RN's, physicians and pharmacists.

The tools developed included increased multidisciplinary education, clear order entry education for all providers, and a PHTN bedside binder which contained several staff resources. Guidelines were initiated related to safe drug administration dosing and medication double checks.

RESULTS: We are still in the implementation phase and continue to gather data from incident reports and process indicator. So far there have been no incident reports pertaining to prostacyclin administration and 90% RN compliance with process indicators reflect the stated purpose of safer prostacyclin management. We perceive that if the tools are utilized at the time of admission and throughout the hospital stay it will create another opportunity to reinforce staff education and performance improvement with the patient related to their drug and equipment management. Ongoing education will be evaluated after each session and basic skills and competency will be re-tested on an annual basis.

DISCUSION/IMPLICATIONS/CONCLUSIONS: By addressing our own centers' issues related to prostacyclin infusions and reviewing the current literature we were able to develop new tools and institute several new safe steps to prostacyclin infusion management for the interdisciplinary team. We look to continue monthly committee meetings to review process indicators of care delivery to pulmonary hypertension patients. As a teaching hospital, we are challenged by the frequent rotation of staff of all disciplines through the units and our ability to educate and maintain competency of each team member.

  1. Kingman, M. S., Tankersley, M.A., Lombardi, S. Spence, S., Torres F., Chin, K.S. (2010). Prostacyclin administration errors in pulmonary arterial hypertension patients admitted to hospitals in the United States: a national study. The Journal of Heart and Lung Transplantation, 29 (8), 841-846.
  2. Chest 2009: American College of Chest Physicians Annual Meeting: Poster 129. Presented November 3 2009. Retrieved July 31, 2011.