For any nurse working in a direct care setting, preparing medications and administering them to patients is part of the daily routine. Mistakes can happen at any point in the process. Administration errors are one of the most serious and most common mistakes made by nurses. The result may lengthen a hospital stay, increase costs, or have life and death implications for the patient. So, what can you do to safely administer medications?
Start with the basics
Minimize distractions and interruptions:
- Verify any medication order and make sure it’s complete. The order should include the drug name, dosage, frequency and route of administration. If any element is missing, check with the practitioner.
- Check the patient's medical record for an allergy or contraindication to the prescribed medication. If an allergy or contraindications exist, don't administer the medication and notify the practitioner.
- Prepare medications for one patient at a time.
- Educate patients about their medications. Encourage them to speak up if something seems amiss.
- Follow the eight rights of medication administration.
Implement these additional safety measures:
- Know that interruptions and distractions have a marked effect on your performance, causing a lack of attention, forgetfulness, and errors.
- Make sure you have all the required supplies and documents available before beginning preparation or administration activities.
- Follow your facility’s policy related to the use of a “No Interruption zone” (NIZ), a practice recommended by the Institute for Safe Medication Practices (ISMP) to enhance patient safety. Your NIZ should be a discreet area where medication tasks are performed. It may be a dedicated medication room or a quiet area sectioned off by visual markers.
- If required by your facility, wear a special vest, apron, sash, lighted lanyard, or other item that indicates that you are administering medications and shouldn’t be interrupted.
- If your facility utilizes mobile devices, temporarily transfer calls and other notifications to another staff member or place the device on pause during the most complex parts of the medication preparation and administration tasks.
- Be especially alert during high-risk situations, such as when you are stressed, tired, or angry or when supervising inexperienced personnel. Monitor and modify work schedules to minimize work- or fatigue-related medication errors.
- Be familiar with all appropriate antidotes, reversal agents, and rescue agents. Know where they are stored on your unit and how to administer them in an emergency situation.
- Be familiar with high-alert medication (such as anticoagulants, antidiabetic agents, sedatives, and chemotherapeutic drugs). Ask another nurse to perform an independent double check and rectify any discrepancies BEFORE administering the drug.
- Be aware of the ISMP’s and your facility’s list of confused drug names, which includes sound-alike (such as Zocor and Cozaar) and look-alike (such as vinblastine and vincristine) name pairs. Take extra precautions when administering drugs from these lists. Your facility may also have extra safeguards in place, such as requiring both the brand and generic name be recorded, including the purpose of the medication with all orders, or setting up computer selection screens to prevent look-alike names from appearing near each other.
- Pay attention to Tall Man lettering, a visual safety feature that highlights a section of a drug’s name using capital letters to help distinguish look alike name pairs from each other, such as BuPROPion (an antidepressant) from BusPIRone (an anxiolytic) or glipiZIDE from glyBURIDE (two different antidiabetics).
- Measure and document a patient’s weight in metric units (grams and kilograms) ONLY to allow for accurate dosage calculations. Also, weigh the patient as soon as possible on admission and don’t rely on stated, estimated, or historical weights.
- For patients receiving IV opioid medication, frequently monitor respiratory rate, sedation level, and oxygen saturation level or exhaled carbon dioxide to decrease the risk of adverse reactions associated with IV opioid use. If adverse reactions occur, respond promptly to prevent treatment delays.
- Administer high-alert intravenous medication infusions via a programmable infusion device utilizing dose error-reduction software.
- Reconcile the patient’s medications at each care transition and when a new medication is ordered to reduce the risk for medication errors, including omissions, duplications, dosing errors, and drug interactions.
- Educate and provide written instructions to the patient and family (or caregiver) regarding prescribed medications for use when at home and verify their understanding prior to discharge.
By being familiar with medications you administer and following safeguards, you can help protect your patients from medication errors.
For more information on medication safety, go to:
CDC: Medication Safety Program
Institute for Safe Medication Practices
AHRQ Patient Safety Network: Medication Errors
US FDA: Medication Errors Related to Drugs
Joan M. Robinson, MSN, RN
Institute for Safe Medication Practices. (2016). "2016-17 targeted medication safety best practices for hospitals" [Online]. Accessed April 2016 via the Web at http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf
Safe medication administration practices, general. (2015). In Lippincott procedures. Retrieved from http://procedures.lww.com.
Nursing 2016 Drug Handbook. (2016). Wolters Kluwer: Philadelphia, Pennsylvania.
Don’t you wish it was that easy? You could just pick up the phone, hire Bugbusters, and they’d come out and use their Sci-fi equipment to rid your facility of all those nasty “bugs” or organisms that cause health care-associated infections (HAIs). Unfortunately, it isn’t that easy; there’s no Sci-fi equipment to magically rid your facility of organisms. We’ve made strides, however, towards reducing the incidence of these infections by using a variety of evidence-based best practices.
The Centers for Disease Control and Prevention recently published the National and state healthcare associated infections: Progress report using 2014 infection data from national acute care hospitals. This report revealed significant progress towards reducing HAIs:
- Central line-associated bloodstream infections declined by 50% between 2008 and 2014.
- Catheter-associated urinary tract infections showed no change overall, but there was progress made in non-critical care settings between 2009 and 2014, and in all settings between 2013 and 2014.
- Surgical site infection declined by 17% between 2008 and 2014.
- Clostridium difficile infections declined by 8% between 2011 and 2014.
- Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia declined by 13% between 2011 and 2014.
As you can see, we’ve made significant progress, but there’s still much more work to be done. Every day, nearly one in 25 patients in the United States has at least one infection that they acquired during their stay in a health care facility. This shows the need to improve infection control and prevention practices in health care facilities, and other various settings.
Bugbusting best practices
So, what can we do to bust those “bugs” and prevent HAIs in our health care facilities? To start, research shows that when members of the multidisciplinary team are aware of infections and join together to take steps to prevent those infections, infection rates can be reduced by more than 70%. Developing a culture of safety that includes teamwork, evidence-based infection prevention processes, and accountability for preventing infections is key.
Making it real
Make infections real to all members of the health care team, including environmental services personnel, transportation staff, sterile processing department staff, patients, visitors, and volunteers; not just those directly involved in patient care. After all, everyone plays a role in preventing the spread of infection.
Share stories… nothing hits home like a story of a patient who suffered harm as a result of an infection that could’ve been prevented. Take for instance, the story of an elderly patient admitted to a health care facility for knee replacement surgery. The surgical procedure itself went smoothly, but the patient soon developed a surgical site infection, the responsible organism was MRSA. The patient spent months in the hospital for IV antibiotics, prosthetic joint removal, spacer insertion, and eventually an above the knee amputation of the affected leg. The patient, the mother of a staff physician, eventually succumbed to complications of the MRSA infection.
How could a seemingly uncomplicated surgery result in an infection that ultimately resulted in this patient’s death? Was it by the hands of a health care worker who didn’t take time to perform hand hygiene? An operating room team member who failed to follow sterile technique during the procedure? An environmental services staff member who didn’t properly clean surfaces in the patient care area? A sterile processing staff member who didn’t properly sterilize surgical instruments? A visitor who failed to perform hand hygiene before visiting the patient? The patient herself who failed to properly perform personal hygiene after surgery? Any of these scenarios could’ve caused the patient’s infection and subsequent death. When this story was told, it was difficult not to feel accountable.
There are many opportunities for infection to spread in a health care facility. It’s important to make sure that everyone is educated about measures to prevent infection, using methods that they understand. Start with the basics...we’ve all heard it before, hand hygiene
is the single most effective thing you can do to keep infection from spreading. Make sure everyone performs hand hygiene properly, every time that it’s indicated.
Develop a culture that has zero tolerance for infection and zero tolerance for failure to follow proper infection prevention practices. Empower patients, family, and other staff to speak up when infection prevention practices aren’t followed. Getting to zero is the only sure way to keep our patients safe from infection.
What infection prevention practices have been successful at your facility? Have you done anything creative to engage staff, patients, and visitors; something outside the box that you’d like to share with us?
Centers for Disease Control and Prevention. (2016). “National and state healthcare associated infections: Progress report” [Online]. Accessed April 2016 via the Web at http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf
Collette Bishop Hendler, RN, MS, CIC
Institute for Healthcare Improvement. (n.d.). “What zero looks like: Eliminating hospital-acquired infections” [Online]. Accessed April 2016 via the Web at http://www.ihi.org/resources/Pages/ImprovementStories/WhatZeroLooksLikeEliminatingHospitalAcquiredInfections.aspx
Yokoe, D.S., et al. (2014). SHEA/IDSA practice recommendation: Introduction to a compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. Infection Control & Hospital Epidemiology, 36(5), 455-459.
Senior Clinical Editor
Clinical Project Manager, Lippincott Procedures
Wolters Kluwer, Health Learning Research & Practice
We’ve all experienced it over the years…the frustration of having some piece of equipment, computer program, patient care process, person, or policy get in the way of getting the job done. Sometimes it’s because the thing or situation that’s standing in our way is broken. Other times it’s because there’s no rule in the playbook that addresses exactly an unusual circumstance. The end result is often the creation of a work-around…
and nurses can be extremely creative!
Work-arounds circumvent established procedures, policies, and processes. In some cases, they truly may be needed to get an essential task accomplished because the current system has not yet caught up to the realities of clinical practice. The work-around may ultimately indeed be the right way, but just continuing to do it informally may be viewed as a much quicker and easier path to travel than the journey to making it a permanent solution. Depending on the nature of the issue and the organizational change process that’s needed, there may be tedious processes to follow, forms to fill out, a chain of command to invoke, a business case to make, committees to form, places to go, and people to see.
In other words, the real solution can appear a far-off, daunting task that requires considerable expenditure of time and energy and quite possibly a measure of stretching way beyond a personal comfort zone into organizational bureaucracy. There’s a very real chance that the proverbial “squeaky wheel” that brings the matter to light could wind up the owner of the issue and be expected to be part of the solution. However, if the work-around makes things look like everything is working just fine, there’s no obvious burning platform as the catalyst for necessary change. The problem may remain invisible to the larger system and go unsolved. If leadership is unaware, there’s no opportunity to submit requests for maintenance or budget for new equipment, system upgrades, or even necessary material or human resources.
Another category encompasses the work-arounds that may simplify the job or allow it to be accomplished faster, but bypass safety measures put into place to reduce risk. Ignoring established safety practices that are perceived as cumbersome is an example. Staff may become so good at these that the work-around escapes detection. These types of work-arounds can evolve to become the usual practice or even the cultural norm. They may be passed along to new staff members as tips or tricks to be more efficient to the point that staff stops seeing the strategy as a work-around at all. Direct observation might be the only way to spot this situation. Nurses who follow the rules can experience considerable moral distress when they discover that co-workers are using such work-arounds inappropriately. They are then placed into the very difficult position of either turning a blind eye (which has significant ethical and even professional regulatory implications), or acting as a whistle blower to management.
My advice is that if a work-around is felt to be necessary, there’s a problem with the current system that must be addressed. That includes those situations where the work-around is done to make the job easier or faster but bypasses safety measures. Perhaps the safety measures could be maintained and risks reduced if the system was re-designed in a way to make it easier to do the right thing while still meeting all of the standards and regulations. Our knee-jerk in healthcare often involves creating a new form to fill-out or coming up with a new tedious process that gives the illusion of a safety improvement, but instead just adds another barrier that people look for ways to overcome. We need to think broadly and be truly innovative. Strategies include researching current best practices, connecting with staff at other organizations to learn how they manage similar issues, and even investigating if there are applicable innovative solutions in industries outside of healthcare.
We do need to make processes associated with nursing practice and healthcare in general safer, easier, more efficient, and more effective. The appearance of a work-around is a red flag for an improvement opportunity. Rather than allow it to persist or remain obscure, bring the situation to light and be an advocate for necessary change. Keep in mind the old adage: if you always do what you’ve always done, you will always get what you’ve always got. When confronted with a work-around, take on the challenge and demonstrate individual leadership, advocacy, and the courage to engage in true problem resolution.
Happy Nurses Week!
Linda Laskowski-Jones, APRN, MS, ACNS-BC, CEN, FAWM, FAAN
Vice President: Emergency & Trauma Services
Christiana Care Health System – Wilmington, Delaware
Safety is something we think about constantly in our daily lives. We look both ways when we cross the street, we buckle our seatbelts when we get into the car, and we put on helmets when we participate in outdoor activities, such as biking, skateboarding and skiing. For many, safety is not an all-consuming concern at work. As health care providers, however, we are exposed to a multitude of dangers every day. According to the United States Department of Labor, Occupational Safety & Health Administration (OSHA), a hospital is one of the most hazardous places to work.1
Health care workers experience some of the highest rates of nonfatal illness and injury – surpassing both the construction and manufacturing industries.2
In 2011, U.S. hospitals recorded 253,700 work-related injuries and illnesses, a rate of 6.8 work-related injuries for every 100 full-time employees.1
At work, I regularly lift, turn and transfer patients with limited mobility, strength and balance. I often encounter confused and combative patients who pose a great risk to themselves and the clinical staff. The threat of a needle stick injury and the possible exposure to infectious diseases are two dangers that are perpetually at the forefront of my mind. In nursing school, we were taught basic ergonomic techniques to protect our backs. We were instructed on procedures to prevent unintended exposure to blood borne pathogens. But in the fast-paced world of health care, where patient loads are high, many of these safety strategies fall by the wayside. By nature, nurses often put their own health and safety at risk for the benefit of the patient.3
So, how safe do we really feel at work and what are hospital administrators doing to protect their employees?
In 1979, Congress passed the Occupational Safety and Health Act, which resulted in the creation of the OSHA. OSHA is the government body responsible for ensuring a safe and healthy working environment for employees by setting and enforcing standards and by providing training, outreach, education and assistance.3
When I began working in the intensive care unit many years ago, I remember having to complete my first annual competency checklist, which incorporated mandatory lectures developed by OSHA. Topics included blood borne pathogens, fire hazards, fall prevention and methicillin resistant staphylococcus aureus (MRSA). Today, those topics have expanded to include latex allergy, equipment hazards, workplace violence, and workplace stress.4
These topics are just a subset of the hospital-wide OSHA standards spanning every department from dietary to central supply to housekeeping.
One area of hospital workplace safety that has received great attention in the media in recent years is the use of Personal Protective Equipment (PPE). This issue was highlighted in the news when the first laboratory-confirmed case of Ebola was diagnosed in the U.S. in September 2014.5
Controversy surrounded this story, which began when a man, who arrived from Liberia initially without symptoms, walked into a Texas emergency room complaining of fever and other flu-like symptoms. After being discharged, he was readmitted several days later and diagnosed with the Ebola virus. Personal Protective Equipment was provided to the staff assigned to the infected patient. Despite these safeguards, however, two clinicians were exposed and ultimately contracted the deadly virus. Thankfully, both nurses survived, but fingers pointed to the hospital administrators, placing blame on their inability to properly educate and ensure the safety of their staff. Were they at fault or just inadequately prepared with minimal resources to deal with this seemingly rare occurrence?
Ebola is an extreme example that emphasized the importance of hospital workplace safety and one that forced hospital administrators across the country to evaluate current policies and procedures. All workers, regardless of the industry, have a right to a safe work environment. Have you noticed any areas of your hospital where improvements could be made to increase overall safety? Do you have recommendations or a success story to share? We would love to hear from you – please leave your comments below.
Occupational Safety & Health Administration (OSHA): Worker Safety in Hospitals
Occupational Safety & Health Administration (OSHA): Hospital eTools
Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation (Joint Commission)
Myrna B. Schnur, RN, MSN
1. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) Worker Safety in Hospitals: Caring for Our Caregivers. Retrieved from: https://www.osha.gov/dsg/hospitals/index.html
2. The Joint Commission: Improving Patient and Worker Safety. Retrieved from: http://www.jointcommission.org/assets/1/18/tjc-improvingpatientandworkersafety-monograph.pdf
3. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) About OSHA. Retrieved from: https://www.osha.gov/about.html
4. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) Hospital eTools: Intensive Care Units. Https://www.osha.gov/SLTC/etools/hospital/icu/icu.html
5. Centers for Disease Control and Prevention (2016). Cases of Ebola Diagnosed in the United States. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html
As health care professionals, there are few things more agonizing than listening to a grief stricken mother describe how her young daughter, bravely fighting cancer, died during a hospital stay as a result of delays and failed communication. Looking at the audience at the Patient Safety Seminar that day, you could see that all of us felt her pain. After all, we got into the medical field to help people, to heal the sick and care for the most vulnerable, but in this case, we failed. Sadly, I have heard versions of that mom’s story many times throughout the years. The specifics change, but the result is the same -- the loss of life or permanent injury as the result of a medical error.
We aren’t perfect, I tell myself, as I hear those excruciating stories. We are human beings and sometimes, despite our best efforts, we come up short. But inevitably, as I let their brave messages sink in, I use those heartbreaking stories to motivate me -- to dig deeper and try harder and to become a more determined advocate for improving patient safety.
The American Nurses Associations (ANA) theme for National Nurses Week this year is Culture of Safety – It Starts with you
. Since the landmark Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System
was released in 1999, creating a culture of safety has been a major focus in our profession. The notion that medical errors resulting in patient harm are largely preventable and a result of system failures provided the platform for health care culture reform.
The IOM report provided clear recommendations to address medical errors. The government, professional organizations, and health care organizations have all worked towards reducing preventable medical errors. There is a plethora of information on culture of safety, including webinars, how to guides, frameworks, guidelines, etc. While we have made progress, preventable harm occurs in hospitals every day.
So what is a culture of safety? A culture of safety is an environment in which patient care is safe and effective, and patients are free from preventable harm. The complexity of systems in which health care is provided makes this challenging, but not
So, how can every nurse take a leadership role in creating and sustaining a high reliability culture of safety?
- Actively engage patients and their family as partners in care.
- Approach care delivery with interprofessional collaboration and teamwork.
- Promote a culture of blame-free reporting of adverse events and near misses; analyze and learn from them.
- Implement evidence-based best practices; remove barriers to ongoing sustainment.
- Maximize the use of technology as intended.
- Improve hand-off communication and transitions of care.
- Maintain a high level of situational awareness in your work area to anticipate problems ie., rounding, huddles.
- Speak-up if you witness or identify unsafe behavior or safety hazards and hold each other accountable to safe practices.
- Establish goals, measure outcomes and promote transparency of data.
During Nurses Week
this year, let us all make a commitment to ourselves, our teammates and those we care for, that we will become better patient advocates. Let us learn from those heartbreaking stories of loss and take whatever steps are needed to create and sustain an environment founded in a culture of safety -- every day and in every way.
Susan Mascioli MS, BSN, RN, NEA-BC, CPHQ, LSSBB
Director, Nursing Quality and Safety
Christiana Care Health System
Happy National Nurses Week!
As we approach the celebration this year, I’d like to take some time to share all that we have coming up for the week and into the rest of the month. There’s a lot of buzz online about what a Nurses Week gift should look like (Read: Not another water bottle. How about safe staffing?) As a leading web resource for nurses, we’d like to do our part to create a culture of safety this Nurses Week by providing you with up-to-date resources based on the latest evidence and reviewed by our peers. Be sure to check out all of our Nurses Week plans
and take advantage of CE collections, free articles, eBook offers, and some opportunities for fun!
I’m excited to share that right here on our blog, we have a wonderful series of posts from nurse experts who’ve shared their insights and knowledge. I’ve enjoyed working with these colleagues – they’ve inspired me and taught me so much as we put together this series. I think you’ll enjoy it!
Here’s what’s ahead:
On another note, I want to let you know that Lippincott NursingCenter.com received the Gold Award from the American Society of Healthcare Publication Editors (ASHPE) for Best Use of Social Media
for our campaigns for National Nurses Week in 2015! Thank you to all of you for your likes, follows, comments, shares, retweets, etc. You were instrumental in helping us to achieve this goal! And congratulations to all the winners of these prestigious awards!
Be sure to follow us on all of our social media channels as we head into National Nurses Week 2016! We’ve got some special offers that you don’t want to miss!
Have a great week, everyone!
Posted: 5/4/2016 10:29:46 PM
Lisa Bonsall, MSN, RN, CRNP
| with 1 comments
Categories: Patient Safety
“The most important thing for nurses to understand about informatics is that it’s not technology. Informatics is not about hard drives, and it’s not even necessarily about programming, and we certainly cannot fix someone’s problems with Outlook. Informatics is about how we’re managing data, information from both a process perspective and a technical perspective to advance health care.” Mollie R. Cummins, PhD, RN, FAAN has been a practicing nurse since 1994 and has made waves in the nursing informatics specialty throughout her career. She holds a doctorate in nursing science and information science from Indiana University, serves as an associate professor of nursing and adjunct professor of biomedical informatics at the University of Utah, and currently serves as the president of the Utah Nursing Informatics Network. Cummins also recently served as editor the ANI Connection and CIN Plus columns of the journal, CIN: Computers, Informatics, and Nursing
Nursing Informatics Day is May 12th and takes place during National Nurses Week
. She says, “It’s important that nursing informatics celebrate its profession in conjunction with nurses week, especially this year because this year the focus is on safety. IT has been identified as one of the most promising approaches for improving safety in the clinical setting. IT-based strategies, such as barcode medication administration, can really reduce safety inefficiencies and vulnerability in the clinical setting, so it’s very important that nursing informatics be a part of this.”
I had the chance to speak with Cummins over the phone about ways to celebrate Nursing Informatics Day and why nurses in all specialties should pay attention to technology in the workplace.
Listen for the whole interview…
Be sure to stop by our National Nurses Week
page for more ways to celebrate, including discounts and giveaways for nurses week! BONUS: Read the current issue of CIN
on NursingCenter for free as our featured journal
until May 15th.
Posted: 5/2/2016 2:49:50 PM
| with 0 comments
I have learned quite a bit on my journey to gaining a better understanding of Negative Pressure Wound Therapy (NPWT). In Part 1
of this series, I provided an overview of NPWT, including what it is, how it works and the risks and benefits. In Part 2 of the series I will review the practical application of NPWT including prescribing orders, procedural steps, general patient care, and tips to troubleshoot the device.
Let’s jump in!
What are the steps in applying NPWT?
Each device has a specific design and manufacturer’s instructions for use that should be reviewed. The following procedural steps provide a general guide.
- Pre-medicate the patient for pain as needed and as prescribed.
- Prepare the wound by:
- removing the prior dressing very carefully to avoid tissue damage and bleeding
- debriding the wound, performed by a qualified practitioner
- cleansing the wound as needed/prescribed
- assessing wound size and depth
- Cut foam dressing to size and place into the wound. Document the number of foam pieces used; foam acts as a filter to catch blood clots and large tissue particles that might clog the vacuum system.
- Trim clear occlusive dressing to size, peel back one side of Layer 1 and place adhesive side down over wound. (see photo 1)
- Remove the remaining side of Layer 1 ensuring it creates a tight seal.
- Cut a hole into the clear dressing about the size of a quarter (2.5 cm). (see photo 2)
- Remove Layer 1 from adhesive pad connected to the pump tubing.
- Place pad and tubing directly over hole affixing it to the clear dressing. (see photo 3)
- Remove Layer 2 from the adhesive pad.
- Connect pad tubing to canister tubing and be sure the clamps are open.
- Turn on power to the vacuum device, set the prescribed pressure settings, and confirm that the dressing and foam shrink down. (see photo 4)
Wound Care Tips:
General Patient Care:
- Use protective barriers, such as non-adherent or petroleum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT. 2
- Avoid overpacking the wound too tightly with foam; this prevents negative pressure from reaching the wound bed, causing exudate to accumulate. 2
- Avoid placing the tubing over bony prominences, skinfolds, creases, and weight-bearing surfaces to prevent tubing-related pressure ulcers. 2
- Count and document all pieces of foam or gauze on the outer dressing and in the medical record, to help prevent retention of materials in the wound; 2 when possible, only use one piece of foam dressing.
- With a heavy colonized or infected wound, consider changing the dressing every 12 to 24 hours as directed by the prescribing clinician.2
Troubleshooting the Device
- Assess the patient for wound healing issues, such as poor nutrition (low protein levels), diminished oxygenation, decreased circulation, diabetes, smoking, obesity, foreign bodies, infection and low blood levels.2
- Assess and manage the patient’s pain; be sure to premedicate as needed before each dressing change.
- Provide patient education on:
- Alarms and device ‘noise’
- Dressing changes
- Signs of complications (bleeding, infection)
- Patients should seek medical care if they notice:
- Significant change in the color of the drainage (cloudy or bright red)
- Excessive bleeding under the clear dressing, in the tubing or in the canister
- Increased redness or odor from the wound
- Increased pain
- The device has been left off for more than 2 hours
- Signs of infection, such as fever, redness or swelling of the wound, itching/rash, warmth, pus or foul smelling drainage
- Allergic reaction to the drape/dressing: redness, swelling, rash, hives, severe itching. Patient should seek immediate medical assistance if they experience difficulty in breathing
- Confirm that the unit is on and set to the appropriate negative pressure, that the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure. 2
- Be sure the negative pressure seal has not been broken and leaks are minimal.4
- Ensure there are no kinks in the tubing and that all clamps are open.4
- Address and resolve alarm issues; reasons for the unit to alarm include: canister is full, there is a leak in the system, battery is low/dead, therapy is not activated.
- Do not leave the device off for more than two hours; while device is off, apply a moist dressing 2 and notify the prescribing clinician immediately.
- Avoid getting the electrical device wet; educate the patient to disconnect the unit from the tubing and clamp the tubing before bathing.
- Check the drainage chamber to make sure it is filling correctly and does not need changing.4
While I am not an expert in the field of wound care, I am now more confident and better prepared to manage patients receiving Negative Pressure Wound Therapy. I would love to hear your experiences. Let me know if you have any tips or other suggestions that can help nurses and patients safely operate and maintain these devices.
1. Centers for Medicare and Medicaid Services. (2014). Negative Pressure Wound Therapy Technologies for Chronic Wound Care in the Home Setting. Retrieved from the Centers for Medicare and Medicaid Services: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id96ta.pdf
2. Rock, R. (2014). Guidelines for Safe Negative-Pressure Wound Therapy: Rule of Thumb: Assess Twice, Dress Once. Wound Care Advisor, 3(2), 29 – 33
3. Federal Drug Administration. (2009). FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. Retrieved from the Federal Drug Administration: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm190658.htm#table1
4. Wound Care Centers. (2016). Negative Pressure Wound Therapy. Retrieved from Wound Care Centers: http://www.woundcarecenters.org/article/wound-therapies/negative-pressure-wound-therapy
Myrna B. Schnur, RN, MSN
Since I began working in a reconstructive surgery clinic several years ago, I have been exposed to a myriad of complex acute and chronic wounds that require advanced treatment modalities, such as Negative Pressure Wound Therapy (NPWT), in order to heal. These devices were new to me, and I quickly realized that they can be a source of great anxiety for both patient and clinician. I decided I needed more information and education on the topic. In Part 1 of this blog series, I will discuss the basics of NPWT, what it is, how it works, as well as risks and benefits.
What is Negative Pressure Wound Therapy (NPWT)?
Also known as vacuum-assisted wound closure (VAC), NPWT is the distribution of negative pressure across a wound1. The therapy, which emerged in the early 1980’s, includes the placement of a dressing (foam or gauze) onto the wound and is connected to a vacuum pump via tubing1
. A clear occlusive dressing is placed on top, forming an air tight closed system. Gentle, controlled suction is applied pulling wound debris into a collection chamber. The Food and Drug Administration (FDA) approved the first device for NPWT in 1997. Currently, there are over a dozen FDA approved devices available on the market1, many of which are small and lightweight, allowing patients full mobility3
. Due to varying designs, it is important that you become familiar with the manufacturer instructions for the specific device in use.
Which types of wounds benefit most from NPWT?
How effective is NPWT?
- Surgical wounds, especially those which need to heal by secondary intention1
- Open abdominal incisions1
- Dehisced surgical wounds1
- Skin flaps and preparation for skin graft sites1
- Traumatic wounds1
- Chronic wounds, such as venous insufficiency ulcers, diabetic foot ulcers, and pressure ulcers1,4
- Wounds at high risk for infection4
- Wounds with copious drainage4
- Meshed grafts, to either secure the graft in place or improve epithelialization4
- Adjunct to skin graft/flap procedure4
Compared to traditional forms of wound therapy, advantages of NPWT include:
What are the factors that increase a patient’s risk for adverse events with NPWT:
- Improved healing of transplanted skin and decreased length of hospital stay for patients receiving split thickness skin grafts.4
- Decreased wound infections in patients following orthopedic trauma and open fractures.4
- Improved wound healing, shorter length of stay, lower hospital mortality in patients with mediastinitis and unsuccessful wound healing following sternotomy.4
- Improved wound healing in patients with diabetes mellitus and gangrene that might require amputation.4
Are there any contraindications for NPWT?
- Increased risk for bleeding and hemorrhage2,3
- Anticoagulant or platelet aggregation inhibitor therapy2,3
- Friable or infected blood vessels2,3
- Vascular anastomosis3
- Infected wounds3
- Spinal cord injury2
- Enteric fistulas2
- Exposed organs, vessels, nerves, tendons, and ligaments3
- Inadequately debrided wounds2
- Necrotic tissue with eschar
- Untreated osteomyelitis2,3
- Cancer in the wound2,3
- Untreated coagulopathy2
- Unexplored fistulas
- Exposed vasculature, nerves3, anastomotic site3, vital organs2
While great strides have been made to improve the safety of NPWT devices, serious adverse events may still occur. Clinicians should take time to review specific device instructions for use, indications, and contraindications and adequate staff training should be provided. Healthcare providers that understand the principles of NPWT can then collaborate to ensure that each patient is selected appropriately for therapy based on wound type, risk profile and care setting. In Part 2
of this series, I will review the procedure for applying a NPWT dressing, general patient care, and tips to trouble-shoot the device.
Myrna B. Schnur, RN, MSN
1. Centers for Medicare and Medicaid Services. (2014) Negative Pressure Wound Therapy Technologies for Chronic Wound Care in the Home Setting. Retrieved from the Centers for Medicare and Medicaid Services: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id96ta.pdf
2. Rock, R. (2014). Guidelines for Safe Negative-Pressure Wound Therapy: Rule of Thumb: Assess Twice, Dress Once. Wound Care Advisor, 3(2), 29 – 33.
3. Federal Drug Administration. (2009). FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. Retrieved from the Federal Drug Administration: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm190658.htm#table1
4. Wound Care Centers. (2016) Negative Pressure Wound Therapy. Retrieved from Wound Care Centers: http://www.woundcarecenters.org/article/wound-therapies/negative-pressure-wound-therapy
This topic came up a couple of times recently – once, in a conversation with nurse faculty preparing courses for undergraduate students; the second, during the Keynote Address at the Dermatology Nurses’ Association Convention. The faculty members were questioning which term – patient or client – is appropriate for use in the academic setting. In her Keynote, Everyday Ethics for Nurses in Everyday Practice,
Leah Curtin, ScD(h), RN, FAAN touched on this topic and even dug deeper into the roots of each of the words, encouraging the audience to make their own decisions regarding the appropriateness of each term.
Here’s a closer look at the terms ‘patients’ and ‘clients.’
- Comes from the Latin word, patior, which means ‘to suffer’
- Defined as ‘one who suffers’
- Comes from the Latin word, clinare, which means ‘to lean’
- Defined as ‘one who is the recipient of a professional service’
Based on the word roots and definitions, some may feel that the term ‘patient’ indicates a hierarchical relationship, where the term ‘client’ signifies a more collaborative relationship. It’s interesting then that many authors, clinician and non-clinician, use the terms interchangeably or even simultaneously. For example, “patient or client self-report measures” or “patient/client safety” is often found in the literature. However, we know that the written word is not how we speak and I’ve yet to hear a colleague ask “Is the patient/client NPO?” or say “The patient/client needs a new IV inserted.”
I was surprised during a search on this topic, to find that this is not a new discussion. In a 1997 article
from the Canadian Medical Association, Peter C. Wing, MB, ChB found that use of the term “client” was documented as early as 1970. He also shares results from his survey of 101 people attending an ambulatory back-pain clinic; almost ¾ of those surveyed stated a preference for ‘patient’ rather than ‘client.’
Personally, I can’t imagine referring to a person in my care as a client. It just sounds unnatural to me. Which do you prefer?
For whom do you care – patients or clients?
Farlex, Inc. (2016, April 8). Retrieved from The Free Medical Dictionary: http://medical-dictionary.thefreedictionary.com/
Wing, P. (1997). Patient or client? If in doubt, ask. Canadian Medical Association, 287-289.
Posted: 4/13/2016 9:18:24 AM
Lisa Bonsall, MSN, RN, CRNP
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