Transcript Managing Concentrated Injectable Medicines

Patient Safety
WHO collaborative High 5s topics
• Prevention of patient care hand-over errors
• Prevention of wrong site/wrong procedure/wrong
person surgical errors
• Accurate medicines reconciliation
• Prevention of high concentration drug errors
• Promotion of effective hand hygiene practices
http://www.who.int/patientsafety/solutions/high5s/en/index.html
SOP - Management of
Concentrated Injectables
“worldwide evidence that concentrated injectable
medicines have been involved in medication
incidents resulting in death or serious harm”
WHO 2007
http://www.who.int/patientsafety/solutions/high5s/Managing-concentrated-injectables.pdf
Basic principles
• Simplify and rationalise protocols and range of
products
• Minimise calculations and preparation in clinical
setting
• Procure ready-to-administer or ready-to use
products that require no further dilution before
use
Identified Conc Injectables
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Potassium Chloride and Phosphate soln
Heparin > 1000units/ml
Concentrated morphine & opiate injections
Hypertonic Saline
Magnesium Sulphate >50%
Any other injections in high concentrations that
cannot be administered safely to patients.
• Injectables as highlighted by reported incidents,
e.g. ciclosporin, tranexamic acid, amiodarone.
Identify
all types & location of CIs
Process Flow used for
Managing Concentrated
Injectable Medicines
Standardize and limit the number
of concentrations
Procure suitable premix bags
Is there still a valid clinical need
for CIs ?
No
Yes
Determine minimum amount CIs
for safe care.
Procure additional premix bags
and set stock levels
Remove CIs from these clinical
areas
Identify secure and segregated
storage of CIs
Ensure Smart pump profile &
Policies/ Procedures current
Procure additional premix bags
and set stock levels
Ensure Smart pump profile &
Policies/ Procedures current
Monitor usage of premix bags
annually
Ensure Smart pump profile &
Policies/ Procedures current
Train authorised staff to access
and use CIs
Evaluate CIs usage and clinical
need annually
Monitor usage of Premix bags
annually
What is the problem?
KCl in Conc ampoule form can be
fatal if not handled properly!
• Usage of KCl ampoules = ??? p.a.
• Essential areas (ICU CCU ED) = ??p.a.
• X reported incidents at XDHB in last 6 months and 1
nationally, all potentially serious.
Action taken already:
• KCl concentrate ampoules stored securely on X wards
in XX
• DHBNZ Audit 2009
• X x KCl premixes in use = XX p.a
• Protocols rationalised to X documents (ICU & Adult)
Date
Description of Incident
Follow up
27-Dec-08 Patiert potassium level was 2.5.
Dr charted 100mls 0.9%saline bag and 14mmol of potassium cholride at
33mls an hour.
Checked the infusion with RN. I went to give the infusion and as soon
as it started patient 7 years old began to yell out in pain. I stopped the
infusion immediately and when I checked the pump it read volume
infused zero mls. The IV line was patent and there was no redness at
The site. I discussed this with Dr and Mum requested it be diluted
further.
The doctor recharted the transfusion to 200mls 0.9% Saline bag with
14mmol of KCl. I again checked this with RN. The infusion was taken to
the bedside and commenced. Again child began to yell out in pain and I
stopped the infusion immediately and when I checked the pump it read
volume infused zero mls. The IV line was checked and it was patent and
there was no redness at the site.
I then discussed with Dr , who re charted
0.45%NaCl + 2.5%Dex 500ml bag with
20mmol KCl. Mum requested that the
infusion start at 30mls an hour, patient
tolerated this reporting no pain and there
was no redness at site, after approximately
one minute Mum requested the infusion
rate increase to 60mls an hour, this was
also pain free. Mum then asked if the rate
increased to 90mls/hour as charted. This
was well tolerated and there were no
further concerns.
06-Mar-09 Pt charted KPO4 20mmol x2 via peripheral line. Nurse identified with
H/Surgeon that pt didn't have CVL. Recharted by H/Surgeon as "KPhos
(per 500mls) 20mmol x2". Nurse gave 20mmols in 500mls over 1 hr –
risk of overload to pt). Identified by another SN and rate slowed to
70mls/hr & Dr advised.
Further information from patient’s chart LH
9/3/09 : Was on D5W at 70mls per hour
then bloods showed low K+ and low
Phosphate. Charted and made up
40mmol/1 lit D5W and given at
500mls/hour (outside of Protocol and
standing order guidelines) until noticed and
stopped by second nurse.
04/06/09 FWD8655 M 63Y, Othapedic Surgery. Pt. arrived in Recovery @1948
after surgery. Supposed to have a GIK running as IDDM Gik from
ECCmade incorrectly with 0.18%NACL and 4%Dextrose Instead of
10%Dextrose with 10mmol KCL. No clear documentation as to change
and fluid incorrectly charted on fluid balance. No signature for order.no
record of when previous infusion had completed. This incorrect fluid
commenced at 1715 in ECC
No labs after 3/06/09. LH Spoke with C/N
to alert to incident. Bag hanging correct on
4.06.09
How do we solve it?
Add 3 more pre-mix bags over next 12 months
and remove ampoules from all but essential
clinical areas.
1. 10mmol KCl in 10% Glucose 500ml (GIK):
• Currently bag made on ward by nursing staff
• Estimate XDHB use @ 5000 bags p.a.
• Premix would replace 5000 KCl ampoules and
glucose bags
• Release 1000hrs nurse’s time to care
• Purchase premix for 1month trial in ward ?
• Ready to start asap.
2. 40mmol KCl in N/Saline 1000mL:
• Currently bag made on ward by nursing staff
• Estimate use @ 1500 bags p.a.
• Purchase premix at $7.5k saving
• Release 200hrs nurse’s time to care
• Replace 6000 KCl ampoules
• Introduce with education
3. Paediatric bag 500ml:
• Formula in consultation with consultants and
Starship not yet finalised. (awaiting Aust stds)
Have we made a difference?
By adding 2 more premix bags, 1 x GIK, 1x N/S with
KCl 40mmol to stock a total of 4 premixes.
XDHB would expect:
• ↓ KCL amps by X p.a.
• Conc KCl removed from wards
• If KCL or K Phosphate to remain as clinically valid then
that could be managed as controlled drug with two
witnesses
• Store KCl amps in essential areas only
• Monitor errors reported
• Minimise volumes of premix stored by improved stock
rotation.
From this to this!
The Productive Ward