From: Ornelas, David

Sent: Tuesday, September 09, 2014 6:06 PM

To: UCH-Neuro ICU Staff All
Cc: Newsome, Franklin; Holden, Mary
Subject: Kaizen Comittee Update

Hey All,
Just a few updates from this months Kaizen meeting.

MDV Audits: while we have improved our mdv labeling compliance, we are required to be
at 100% compliance with Joint Commission. Please continue to use pink expiration labels
AND patient label for all open mdv in room, as well as keep them in the locked drawer.
Frank is working on getting the keys made and they will be distributed when able.
Pharmacy will be adding a laminated tip sheet by each pyxis detailing instructions on
what to do when a pt is not in the pyxis and we need medications asap. We will attempt to
make a copy and briefly do some education in huddle on this matter. We will be available
for any questions regarding such.
Our compliance for linking override pulls in epic is low. Please try to link all override pulls
as soon as there is an order in epic or after pharmacy has verified the medication. It is
especially important to link all override pulls prior to a pt transferring to another unit as
the orders change and there is no way to go back and correct this. Remember the 5
Rights of patient medication administration and chart accordingly.
IV Tylenol will no longer be available. Several factors have weighed in on this decision
including, cost, effectiveness, and order restrictions.
Pharmacy will now be stocking Vancomycin 1250mg and 1500mg bags in the medication
fridge. If your patient has this medication and dose ordered you will remove it much the
same way any refrigerated medication, however, it will be in a generic bin, not pt specific.
These bags will be good in the fridge for around 50 days after being mixed and pharmacy
will be cycling them accordingly but please remember to double check the expiration date
before hanging.

Any questions on any of the above please dont hesitate to ask.

Thank you,
David Ornelas RN, BSN
Megan Mahaney RN, BSN
From: Ornelas, David
Sent: Thursday, September 18, 2014 12:30 AM
To: Heissel, Jaclyn J
Subject: FW: override pull reports

Jaclyn,
So, to update you after speaking with Krystal on Tuesday I think this is what I am going to do for
my project. I believe she said your idea for the order sets is being handled by someone else at
this moment. I am done for the week but would like to get together next time we work, which
looking at the ansos sheets isnt for a while. At any rate, Krystal suggested I try to roll out the
education piece asap, preferably by the end of the month/early October as this is an issue that
needs rectified right away.
To summarize the idea:

Based on the information from the Kaizen Committee meeting and input from Krystal, there is a
large gap in the medications nursing overrides and the correct linking of said meds in epic. I will
forward you the baseline data that was sent to Krustal from pharmacy. In just one week there
were a significant number of override meds that had no action taken to them. Whats more
shocking is the number of narcotics and controlled substances without documentation.
To start working on the education piece, how does preparing a powerpoint with the correct ways
to document override pulls with screen shots in epic, present this at the next staff meeting in
October and also prepare a poster board for the huddle room with said powerpoint?? As far as
the pre/post data, Krystal said a survey or questionnaire to the staff wouldnt be necessary since
I can use the data from pharmacy as the pre data. Do you think something more would be
necessary?
I am currently waiting for a reply from Chris to go over the data, and also waiting on Angie from
the Kaizen committee to provide the education tip sheets to begin making the powerpoint. Also,
when I meet with Chris I will see what ideas she has for the night shift as we do not have the
luxury of having a PharmD on the unit like day shift to correct orders when override pulls do not
match up.
How does this sound?
Thoughts?
Thanks Jaclyn,
David Ornelas
From: Ornelas, David
Sent: Wednesday, September 17, 2014 5:45 AM
To: Steckline, Christine; Chamberlain, Krystal R
Subject: RE: override pull reports

Hi Chris,
Thanks so much for getting back to us. As I work night shift, I guess I am looking for what your
schedule looks like. I would preferably like to meet after a shift if able. What time do you get in? I
work again tonight, Wed Sept 17 and could stay after shift if you come in at 8, however, I can be
flexible since we are pushing for staff education at the end of the month.
As far as the data, you can just start sending reports one week at a time as you did when able.
Thanks again and I look forward to working with you.
David Ornelas RN, BSN
Charge Nurse Neuro-Surgical ICU

From: Steckline, Christine

Sent: Tuesday, September 16, 2014 8:20 PM
To: Chamberlain, Krystal R
Cc: Ornelas, David
Subject: RE: override pull reports

Krystal
Yes, I can run this.I will probably have to do this for a week at a time though due to limitation of
not bogging down the system. When do you want these? Yes I can meet with David with or
without you to discuss these overrides.

Just let me know when you want to meet.

Chris
Christine Steckline, PharmD.
Pharmacy Manager, Epic
Epic Willow Analyst
University of Colorado Hospital
7901 E. Lowry Boulevard, Suite 350|Denver, CO 80230
Telephone: 720-553-1806
Pager: 303-266-1842

From: Chamberlain, Krystal R

Sent: Tuesday, September 16, 2014 6:25 PM
To: Steckline, Christine
Cc: Ornelas, David
Subject: override pull reports

Hi Chris,
After looking at the data for override pulls last week in the Neuro ICU, it appears that there is a
lot of room for improvement! One of our charge nurses, David Ornelas, wants to use this data as
part of his quality improvement project for credentialing this year. Would it be possible to send
him a report for the first quarter of this FY? Also, we discussed meeting to look at trends in the
data you sent for the one week in August. I would like to leave this to David to set a meeting with
you in order to assess trends and educational needs. I have ccd him in this message. Please let
us know if this is feasible and if you will be able to meet to discuss. Thank you for your time.
Krystal Chamberlain, RN, BSN, CCRN
Neuro ICU Interim Nurse Educator
University of Colorado Hospital
Office 720-848-7006
Pager 303-266-1823
krystal.chamberlain@uch.edu
The Department of Professional Resources improves lives by empowering healthcare professionals to
influence quality care through education, discovery and navigation of change.

From: Ornelas, David

Sent: Tuesday, March 03, 2015 8:08 AM
To: UCH-Neuro ICU Staff All
Subject: Pharmacy Update

Good Morning Team,

Just a quick update from the Kaizen Committee.

Starting today, March 3rd, UCH is having a system wide change to a few medications. Most of
them will not be a change for us but please make sure you are double checking all new drips and
pumps to ensure patient safety.
Dopamine is 800mg/250ml
Dobutamine is 1000mg/250ml
Amiodarone continuous infusion is 360mg/200ml
Amiodarone loading dose is 150mg/100ml
Fentanyl is 2500mcg/50ml
The plan for Tuesday March 3rd is if the pt is on a different concentration than the new
standard concentration, the unit pharmacist will discontinue the current order and reorder the med with the new standard concentration. Again, please double check the
new bag/vial with the previously inputted data in the pump.
Along those same lines, Krystal Fulton sent an email that a new dataset is being released today,
March 3, 2015 for the Alaris pumps. Please see the details below for properly accepting these
new changes.
Please continue to make sure all patient medications are being transferred with them. This
includes everything from the locked draws, pt specific bins, the fridge, and tube feedings. This
will drastically cut down on cost to the pt. Thank you!
Next month at the Kaizen meeting we will be going over the override drug list. Meaning we will
look at what needs to be added and what can we do without override priveledges. I want to add
23% and Ancef to our override capabilities. If you can think of any others that you have tried to
override but cant please let me know and I will take it to the meeting.
David Ornelas RN, BSN
Charge Nurse, Neuro-Surgical ICU
University of Colorado Hospital
From: Ornelas, David
Sent: Wednesday, June 03, 2015 7:55 PM
To: UCH-Neuro ICU Staff All
Subject: Kaizen Committee Update

Hello Everyone,
Just a few updates from the May and June Kaizen Committee meeting:

We are doing a great job labeling our multi dose vials! Our unit and hospital average is at
a record high of 98% compliance! Keep up the good work. Remember to label all multi use
medications with a pt sticker and pink expiration sticker. These should be in both med
rooms. If not, please let me know.
The committee is currently working on changing our clear plastic medication cups to more
accurate cups that indicate each mL for accurate administration. This will hopefully cut
down on potential over and under dosing of liquid medicaitons. We also advised adding
much less expensive and less harsh on the environment paper cups for simple pill
administration. Product availability and financial issues are being investigated. More to
follow. This is one of ISMPs (Institute for Safe Medication Practices) Recommended Best
Practices for 2014-2015.
One TPA vial is priced at $8300!! If this drug is mixed but not administered, it can be
returned to the manufacturer for a reimbursement to the hospital. Pharmacy is responsible
for the mixing and drawing up of the TPA, however, if you are ever in a situation when TPA
is ordered, mixed, but not used, check with pharmacy to make sure they are going to
return this medication properly. Huge cost saver to the hospital.

Education material posted on the June education board under Pharmacy update.

Thanks and have a great rest of the week!

David Ornelas RN, BSN
Charge Nurse, Neuro-Surgical ICU
University of Colorado Hospital