Chandra Simpson, clinical nurse education specialist; Aleena Peter, clinical nurse II; Amanda Melchiore, nurse manager; Laura Todaro, clinical nurse education specialist; Veronica Pizzuto-DeLuca, nursing informatics coordinator; Nicholas Friia, clinical pharmacy informatics manager
Crucial information about medications often can only be found in the fine print. Thanks to safety-minded teams at Pennsylvania Hospital, now an important precaution for some drugs appears on the primary page for the affected medications in PennChart across the health system.
This change began with a patient who arrived to PAH with a feeding tube, having difficulty eating and drinking. Following the usual protocol for patients with swallowing difficulties, nurses crushed the patient’s chemotherapy drugs into a powder and administered them through the tube. When the patient was moved to a different unit and required their next dose, one nurse, who had expertise on the particular drug, knew that it was not meant to be crushed. The patient wasn’t harmed – but crushing the medication meant that it was less effective, and put the nurses at risk for drug exposure. The nurse placed a report with Penn Medicine SafetyNet, and the result was a system-wide transformation.
“It wasn’t any one person’s fault. There were multiple people involved in different units who were all following protocol,” said Amanda Melchiore, MS, BSN, RN, NPD-BC, PCCN, nurse manager of Intermediate Critical Care.
Melchiore investigated the incident with the ICCU nursing staff and retraced the administration route, finding that it did not specify “Do not crush or chew” on the primary page for the drug in PennChart, as opposed to other drugs that displayed this instruction on the primary page. It turned out the drug included the instruction, but it only was displayed after expanding reference links that provided extensive details about the drug in the PennChart system.
“That’s not the reality of practice at the bedside to be searching through fine print to find this key information,” said Melchiore.
Melchiore placed a ticket with Information Services (IS) to revise the display of the medication instruction, working with colleague Laura Todaro, MSN, RN, PCCN, OCN, a clinical nurse education specialist, and PAH’s Informatics Team, comprised of Internal Medicine physician Joel Betesh, MD; Clinical Pharmacy Informatics Manager Nicholas Friia, PharmD; and Nursing Informatics Coordinator Veronica Pizzuto-DeLuca, MSN, RN. Together, they worked with IS at a system level to apply “Do not crush or chew” as indicated to any medication that did not include these instructions on their primary page in PennChart. For medications that required any additional precautions, the team included bold text to alert staff to view the reference links before administering.
The result of this SafetyNet report was recognized at last year’s Josie King Hero Award ceremony, hosted by PAH’s Quality and Safety Council. Established by the Josie King Foundation – a national organization focused on preventing medical errors and improving care – the award recognizes clinical staff who have demonstrated a commitment to maintaining a culture of safety in their workplace.
“It’s encouraging to work at a health system that supports a strong culture of safety,” said Melchiore. “This experience showed the value of the SafetyNet.”