In November 2017, Allie Sment, ICU RN presented ICU Practice council with the Joint Commission Standards related to medication titration. Current order sets and practices at that time presented gaps in meeting TJC standards. Nurses were essentially practicing medicine and/or outside their scope without proper titration orders and starting doses in place.
Alison led the project by performing a formal gap analysis of current practice in relation to the standards. She shared this information with Pharmacy leadership and states that ICU Practice Council wanted to collaborate on a process improvement project geared towards aligning with the standards. Alison developed a draft of all the current medication infusions and coordinated an interdisciplinary review to ensure proper dosing components. At the same time, Alison was made aware that Alec Dishaw, ICU RN, and member of the ICU Education & Professional Development Council was updating the ICU Medication Infusion Reference form in the unit bedside reference binders. Together, they worked to share their information, assessment, and recommendations with Pharmacy. The networked within the organization to identify the most appropriate venue to partner with key stakeholders. Alison and Alec determined the Medication Safety Committee, led by Jan Fuchsen, was an excellent forum to tackle this important practice and medication safety topic.
Together with Pharmacy, Clinical Application Coordinators, Quality, and Nursing services, Alison and Alec developed order sets to meet TJC standards for medication titration. A plan for education and dissemination of changes was agreed upon and on September 4, 2018, the facility went live with the order sets. The outcome was significant. TJC visited the organization shortly after that and we demonstrated compliance with medication titration standards, ensuring safety for Veterans, nursing staff, and the organization.
This project is an excellent example of the ICARE values and the spirit of teamwork. The nurses leading this team identified a safety issue, sought out the evidence, partnered with interdisciplinary teams, and demonstrated an improved outcome for Veterans and the organization. Kudos to you all. Please know how much your hard work and leadership is appreciated.
Pictured: Sandra Arntzen, BSN, RN ICU Assistant Nurse Manager, Angelina M. Kinter, MSN, RN, ICU Nurse Manager, Alec Dishaw, BSN, RN, William Blaser, PharmD, Katherine Dooley, BSN, RN, Jennifer Hansen, BSN, RN, Mary Solorzano, BSN, RN, Jesse Berndt, BSN, RN, Alethea Sment, MSN, RN, Christopher Jahr, MSN, MHA, RN Division Manager Acute Inpatient Nursing