Power Hour Breakout
A trend was discovered through in-depth investigation of all serious harm PIVIEs occurring at a 432 bed pediatric medical center in 2018 that identified vesicant medications, specifically Calcium Chloride and Calcium Gluconate given in emergent situations, as the causality of these events. A dedicated, physician-led Wound Care Team collaborated with the Vascular Access Team in establishing protocols and quality initiatives through multiple channels that have led to the reduction and hopefully sustained elimination of these serious harm PIVIE events. Collective efforts of engaging front line nursing staff in early identification as well as standardized hand-off and documentation of vesicant medication administration and infiltrations have driven the organization-wide focus of harm reduction from the these events. Early recognition and aggressive intervention and treatment of Calcium and other vesicant infiltrations by the Vascular Access Team and the Wound Care Team have also played an instrumental role in driving down serious harm infiltration rates.