This simple way of identifying at-risk patients has helped Mayo achieve a 98% compliance rate for the mandatory prerelease assessments, while illustrating the effectiveness of the quality assurance planning process that led to the new policy in 2010.
Stacy Schultz, a quality improvement specialist at the Mayo Clinic, described during a scientific session at the 2010 RSNA meeting in December the highly formatted steps taken to identify a workable solution.
The unauthorized release of patients sedated with Benadryl or Ativan to combat MRI-related claustrophobia can have fatal consequences, Schultz noted. In 2003, a patient who had been sedated for MRI at a Minneapolis-area imaging center died after crashing his car on his way home from the procedure.
Mayo's attitudes toward sedation are reflected in policies designed to protect its patients. Patients scheduled for minimal sedation must arrive for the appointment with a responsible adult to ensure safe transportation home after the procedure. Appointments are rescheduled for patients who arrive without such support, or their procedures are performed without sedation, Schultz said.
Yet Mayo still proved vulnerable despite this policy. In September 2009, the registered nurse managing the radiology department's safety event database found that nine minimally sedated MRI patients left the facility without a postsedation assessment. All of the events stemmed from a single imaging service on the Mayo campus.
A front-line quality improvement team, representing a cross-section of the imaging staff, was organized in October 2009 to identify the source and solutions to the problem, Schultz explained. The team included an imaging assistant, two registered nurses, two MRI technologists, a technologist supervisor, a nursing supervisor, the event manager, and Schultz.
"This was key because everyone involved in the process played a role in the evaluation," she said. "Problems and solutions emerge by looking at the big picture."
By performing a failure mode and effects analysis, the team learned the problem cases arose after the department converted from a hard-copy paper safety form for individual patients to an electronic version of the same document.
"The technologists relied on the paper form as a trigger telling them that the patient had been sedated," she said. "Their cue was lost when the department converted to an electronic form."
Additional analysis led to the creation of color-coded stickers denoting patient sedation for the patient's safety form and a corresponding color-coded wristband to be worn by patients. Hot pink was selected at first, in December 2009, but the department shifted to teal two months later after the Minnesota Hospital Association recommended pink wristbands for patients with a restricted extremity affecting the appropriate administration of contrast media and intravenous drugs, Schultz said.
The new safety procedures were implemented at all imaging services at Mayo's Rochester campus in February 2010. Though a few subsequent problems with proper documentation arose, no events relating to patient release without a nurse's assessment were reported from May 28 to September 30, 2010, Schultz said.
"A radiology-specific event reporting system helped us identify this gap in our patient safety," she concluded. "By involving front-line staff and using quality improvement tools, we were able to address this gap and implement a solution."
By James Brice
AuntMinnie.com contributing writer
January 17, 2011
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