Preventing a Fatal Epidural Event Here! The Who, the Why and the What of Examining Latent System Gaps In Your Practice Setting

Purpose for the program:

Unnecessary maternal deaths due to error in administration of epidural medications have occurred in the United States. Normalization of system gaps has taken place as the rate of epidural anesthesia during labor has increased. This presentation will allow the learner to have access to tools that will guide them through a systematic analysis of their workplace to make changes that facilitate a safer environment for patients.

Proposed change:

Catastrophic events have occurred that of course affect families, but also the health and well being of nurses. Making changes that facilitate the recognition of epidural safety, such as standardization of epidural tubing, utilizing epidural pumps that are on a separate pole from IV solutions, marking the epidural bag in the pharmacy with a yellow label and marking the epidural pole with yellow tape to facilitate a visual connection are a few changes that increase safety at the bedside.

Implementation, outcomes and evaluation:

Utilizing an assessment tool, a multidisciplinary team, during a rapid team assessment period made more than four changes in an 6 week window to improve the safety of women undergoing epidural procedures. Additional changes were made throughout the team assessment period that involved additional disciplines and coordination.

Implications for nursing practice:

Improved patient safety is a goal every nurse lives: it is part of their scope of practice as a carative specialty. Reviewing patient injuries and deaths of patients undergoing epidurals caused by medication error allows nurses to review their own practice and put safety guards in place to minimize the chance for an error in their practice.

Keywords: epidurals, patient safety, epidural-intravenous route mix-ups, reducing risk, maternal death