The goal to administer tissue plasminogen activator within 60 minutes of patient arrival to the Emergency Department is attainable through rigorous attention to a standardized process and interdisciplinary collaboration.
This pilot sought to enhance safety and improve reliability of administration for tissue plasminogen activator with implementation of a time out prior to administration.
An interdisciplinary team designed an improvement strategy related to the process reliability of tissue plasminogen activator administration. Four errors occurred in 12 months, a failure rate of 10¯1 (failure of 1 in 10 administrations). Primary goal: design a process with a failure rate of <10¯3 (failure of 1 in 1000 administrations). Secondary goal: ensure alignment with current work flow associated with bar code medication administration. The concept of a safety time out was adopted with 7 confirmatory elements: time last known well, blood glucose, anticoagulation status, blood pressure, contraindications, team consensus, and assurance of a patent intravenous catheter. The Informatics team designed a tool within the electronic health record. A standardized communication process was written. Participants in the time out included a physician and nurse at the patient’s bedside. All stakeholders received training. Prior to redesign, there was a failure rate of 10¯1 with confirmation of all safety elements in 88% of tissue plasminogen activator recipients. The time out procedure was trialed in 5 patients with 100% compliance and an extrapolated failure rate of 10¯3. The average door to needle time was 60 minutes versus 69 minutes prior to the pilot. The time out process took less than 1 minute in all cases. In this group, the time-out successfully identified a missing element - a blood glucose result - the process was stopped until the result was available.
The redesigned process is safe. There was no negative impact to achieving the standard of care. The primary goal of 10¯3 performance was achieved. Secondary goal: alignment with current medication administration process achieved. Unanticipated results: decrease door to needle time and greater satisfaction with a collaborative approach to medication administration.