By DR. ASHLEY TIPPINS & DR. SARAH BROWN
According to The Joint Commission Sentinel Event Database, approximately seven percent of all medication errors related to anticoagulants were reported in inpatient hospitalizations, with two-thirds being related to heparin therapy.1 The Institute of Medicine (IOM) indicates that medication errors are the result of 7,000 deaths that occur yearly in the United States.2 The World Health Organization (WHO) has made patient safety a global concern due to medical errors being the third leading cause of death in the United States.3 Heparin has a narrow therapeutic index; therefore, one of The Joint Commission National Patient Safety Goals is to reduce the risk of harm associated with anticoagulation therapy.4 The Joint Commission has recognized intravenous heparin therapy as a high alert medication that requires evidence-based protocols to be implemented and followed by nurses in the acute care hospital setting to ensure patient safety and to reduce the risk of harm.4
The purpose of a need’s assessment is to gather the necessary information to formulate a plan for the Doctor of Nursing Practice (DNP) project.5 A comprehensive needs assessment was conducted at the DNP project practice site utilizing in-person interviews gathered from staff nurses, nurse educators, nurse managers, the pharmacy department, and nurse directors.
The Director of the Pharmacy department at the DNP project site, provided a report from 2018, 2019, and 2020 identifying the reported medication errors involving anticoagulant medications. The combined three-year reports indicated there were 74 actual medication errors reported involving anticoagulant medication intravenous heparin (IV) therapy. Some of the identified causes of medication errors based on the hospital event report system involved hospital staff lack of initiation of IV heparin therapy in a timely manner, non-nursing and nursing staff discontinuing IV heparin therapy without a physician order, lab not providing timely partial thromboplastin time (PTT) results for IV heparin therapy adjustments, nurses failing to follow IV heparin therapy protocol/policy for administration, and administration of the wrong dose of IV heparin therapy. Literature states that a proper needs assessment identifies the difference between what is being done and what should be done.5
The federal government and The Joint Commission have mandated hospitals to use EBP, standardized protocols, and guidelines to achieve best patient outcomes.6 The Joint Commission has mandated that a standardized handoff communication be utilized in the hospital setting to translate critical and vital patient care information to decrease errors and provide continuity in patient care.7 When examining handoff communication in the acute care hospital setting, consistency has been identified to be the key element in maintaining therapeutic partial thromboplastin times (PTTs) with IV heparin therapy. Some identified barriers to the breakdown of handoff communication include noisy, hectic, and unorganized environments that are at risk for frequent patient care interruptions, time constraints, emotional stress, information/work overload, poor attention, and multitasking.7
The literature review provided evidence that the use of a structured, standardized handoff communication tool and standardized protocol with the support of teamwork ensures the best delivery of safe IV heparin therapy initiation and administration within the healthcare setting and decreases the stress level and anxiety perceived by nurses. The key concepts illustrated and discovered from the highest level of evidence literature search included standardization, teamwork, protocol, handoff communication, and anxiety.
The DNP project effectiveness was examined with the use of central tendency to determine if the participant’s scores after implementation of the IV heparin therapy safety protocol checklist and IV heparin therapy nursing handoff communication guide resulted in an improvement in knowledge base and anxiety level. The demographic survey was used to evaluate and provide an accurate representation of the participants in the DNP project.
The summative evaluation allows the project manager to evaluate outcomes and determine if benchmarks were met.
The data was analyzed to determine whether the participants’ knowledge base increased, and anxiety level decreased after the educational session regarding IV heparin therapy safety protocol checklist and handoff communication guide. The original expected benchmark outcome was a 30 percent improvement in the posttest results from the pretest results. The post data analysis did validate the literature review findings that a structured, standardized educational IV heparin therapy safety protocol checklist and handoff communication increases the nursing knowledge base when providing care for patients receiving IV heparin therapy in the acute care hospital setting. The post data analysis failed to support the hypothesis that providing a structured, standardized educational IV heparin therapy safety protocol checklist and handoff communication guide decreases anxiety level among nurses in the acute care hospital setting when caring for patients receiving IV heparin therapy.
The implications of the project findings validate that acute care organizations should provide registered nurses with the proper education and guidelines to initiate and administer IV heparin therapy that will lead to an improvement in nursing and patient outcomes. There will continue to be a gap in nursing care and deficient patient outcomes without these guidelines and continuing education. There was a sufficient increase in data related to the nurse’s increase knowledge support the need to provide a robust of education that uses a step-by-step approach to providing safety and efficiency in IV heparin therapy care of patients in the acute care hospital setting. Although the results from the project does not provide reliable data to support a decrease in nursing anxiety levels using therapy safety protocol checklist or handoff communication guide.
In summary, IV heparin therapy care should provide healing and not harm to the community. Suboptimal care has been long used to describe healthcare that is less than expected. A step-by-step checklist approach to ensuring safe and effective IV heparin therapy in the acute care hospital setting should be the goal for all organizations. The IV heparin therapy safety protocol checklist and handoff communication guide are equitable, simple, predictable, standardized means to enhance communication and ensure quality in patient-centered care. System redesign with the mitigation of medication errors can ensure safe nursing care with every IV heparin therapy administration.8 Although the outcomes did not reflect a tremendous improvement in the participants’ anxiety level or education knowledge base when caring for a patient receiving IV heparin therapy, the data did reflect that the participant did have a gain in knowledge and not an increase in anxiety level after using the IV heparin therapy safety protocol checklist and handoff communication guide. Future studies could provide an opportunity to reevaluate the care model delivery system that could assist with the revitalization of existing guidelines and protocols in the acute care hospital setting.
Ashley Tippins, MSN, FNP-C
Dr. Tippins, DNP, APRN, FNP-C is from Wetumpka, AL. She has been a registered nurse practitioner for 3 years and a registered nurse for 17 years. Dr. Tippins medical background includes acute care, post-acute care, prison health, and pediatrics to name a few. She currently works with Urgent care for children, Progressive Health, and The Alabama State University. Dr. Tippins completed her Doctoral of Nursing at Purdue Global University.
Dr. Sarah Brown, DNP, APRN, ANP-C
Dr. Brown is a doctorally prepared nurse practitioner, currently employed as full-time faculty and course lead at Purdue Global University. Dr. Bown was awarded top course lead in 2020 by her peers and serves as subject matter expert for course revisions. She maintains clinical practice in women’s health for the past 15 years and is an active member of her local Nurse Practitioner Council. She has precepted NPs in many setting and is certified by the American Academy of Nurse Practitioners since 2006. She has published a project on medication adherence in Today’s Geriatric Medicine Journal.
1. Johnson, C., Miltner, R., & Wilson, M. (2018). Increasing Nurse-Driven Heparin Infusion Administration Safety: A Quality Improvement Initiative, MEDSURG Nursing, 27(4), 243-246.
2. Aldhafeeri, N.A., & Almatrouk, R. (2019). Shaping the Future of Nursing Practice by Reducing Medication Error. Pennsylvania Nurse, 74(1), 14-19.
3. Tingle, J. (2017). World Health Organization: Providing Global Leadership for Patient Safety. British Journal of Nursing, 26(13), 778-779.
4. Marek, J.F. (2019). Safe Use of Anticoagulants—Another Year as a National Patient Safety Goal. Med-Surg Matters, 28(1), 12-13.
5. Zaccagnini, Me. E. & White, K. W. (2017). Clinical Scholarship and Evidence-Based Practice.
6. Upshaw-Owens, M. (2019). Standardization: A Concept Analysis. MEDSURG Nursing, 28(2), 132-134.
7. Taylor, J.S. (2015). Improving Patient Safety and Satisfaction with Standardized Bedside Handoff and Walking Rounds. Clinical Journal of Oncology Nursing, 19(4), 414-416.
8. White, K. W., & Zaccagnini, M. E. (2017). The doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing (3rd ed., pp. 454). Burlington, MA: Jones & Bartlett Learning.