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1、RecommendationOrganization AssessmentAction Required/ AssignmentDate CompletedFatal PCA adverse events linked to inadequate monitoring (11)An opioid-nave surgical patient was started on morphine patient-controlled analgesia (PCA) with a 3 mg demand dose, 10 minute lockout, and a basal rate of 1 mg/h
2、our. During the first night, the patient was found in respiratory distress and died. Gaps in patient monitoring, including a failure to employ pulse oximetry despite the presence of the equipment in the patients room, were the predominant factors, as was the failure to recognize progressive signs of
3、 impending respiratory depression.Along with a basic physical assessment and vital signs, other parameters are vitally important when monitoring patients receiving PCA. The patients level of pain and sedation must be continually assessed; early recognition of excessive sedation and intervention is e
4、ssential. Respiratory assessments should include evaluation of the rate, depth, quality of respiratory effort, pattern of respirations, and breath sounds. Technology to continuously monitor ventilation in patients known to be at risk for respiratory depression is recommended. High-alert medication l
5、ist useless without bundled risk-reduction strategies (7)Some hospitals have neither a well-reasoned list of high-alert medications nor a robust process for managing the drugs on their list. The list may not be well known to clinicians, and hospitals may rely on low leverage risk-reduction strategie
6、s to prevent errors. A list of high-alert medications is relatively useless unless it is up-to-date, known by all clinical staff, and accompanied by vigorous risk-reduction strategies which are more effective than awareness, manual double checks, and staff education.Periodically update your hospital
7、-specific list of high-alert medications, and implement risk-reduction strategies that address the underlying causes of errors, which have been identified through a literature search, information from ISMP, analysis of internal reports, and failure mode and effects analysis (FMEA). Layer numerous ri
8、sk-reduction strategies (see Table in full article) that impact as many steps of the medication process as feasible. Assess the effectiveness of strategies. NAN Alert: Mix-ups between ado-trastuzumab emtansine (KADCYLA) and trastuzumab (HERCEPTIN)(8)The US Food and Drug Administration (FDA)-approved
9、 generic name for Kadcyla, ado-trastuzumab emtansine, may not be fully communicated when prescribed or may be read incompletely, thus risking confusion with trastuzumab. Given that the dosing and treatment schedules for these drugs are quite different, confusion could lead to dosing errors and poten
10、tial harm to the patient. Ensure that you are using the prefix “ado” with “trastuzumab” when referring to Kadcyla. Use both the brand and generic name when communicating orders on preprinted order sets or in computerized order entry systems for either of these drugs. Employ strategies to differentia
11、te Kadcyla and Herceptin generic names and increase awareness of this issue.NAN Alert: Heparin label changes (12)As of May 2013, heparin labels must express the total amount of units in the container and the units per mL in parentheses, rather than just the units per mL. Before the change, the per m
12、L quantity had been misinterpreted as the total amount per container, which led to overdoses and some fatalities. Errors are still possible during transition in which vials with the old and new label are both available, particularly as staff get used to the new label and then encounter a vial with t
13、he old label. To minimize the risk of confusion, hospitals should consider transitioning fully to the newly labeled heparin, even if it means discarding some older vials. Otherwise, separate heparin vials with the old labeling from those with the new labeling, and use all vials with the old labeling
14、 first. As space permits, pharmacy and nursing databases should express drug amounts the same way as the vial label (i.e., 10,000 units/10 mL 1,000 units/mL).Assessment shows widespread lack of knowledge regarding safe use of opioids (7) A Pennsylvania Patient Safety Authority knowledge assessment o
15、f prescribers, pharmacists, and nurses found that 78% did not know a patients level of sedation was the most important predictor of respiratory depression while receiving IV opioids; 33% were unaware that 0.4 mg of HYDROmorphone IV is equianalgesic to 2 mg of morphine IV. Other low-scoring questions
16、 dealt with drugs that potentiate opioid effects, the definition of an opioid-tolerant patient, and indications for using long-acting opioids.Based on the results of the opioid knowledge assessment, organizations should use a similar tool (www.ismp.org/sc?id=205) to assess the understanding of presc
17、ribers, pharmacists, and nurses who care for patients receiving opioids and provide staff education based on the findings along with other safeguards ISMP has published (www.ismp.org/sc?id=210). Confusion regarding overfill with IV chemotherapy(8) More than 1,100 patients may have received lower dos
18、es of cyclophosphamide and gemcitabine than prescribed. The amount of overfill in the containers was not clear, and nurses failed to infuse the entire volume in each bag (including overfill), resulting in administration of lower doses than intended.Establish a standard process to identify the overfi
19、ll volume on the pharmacy label for compounded IV chemotherapy/biotherapy solutions. Ensure that nurses who administer these products can locate the final volume on the label, and can recognize that the full volume must be infused to administer the correct dose (unless otherwise stated). Mix-ups bet
20、ween leucovorin and LEVOleucovorin (13) Two errors occurred at a hospital involving mix-ups between leucovorin and LEVOleucovorin (FUSILEV) due to name similarity. There is significant potential for dosing errors when interchanging leucovorin and LEVOleucovorin. The dose of LEVOleucovorin is one-hal
21、f the dose of racemic leucovorin injection (leucovorin).Separate the drugs wherever they are stored. If using automated dispensing cabinets (ADCs), consider using tall man lettering for LEVOleucovorin in ADC software listings. Pop-up messages should also be considered, as they may be useful to educa
22、te, alert, and remind staff of a possible mix-up.Name confusion with new cancer drugs PAZOPanib (VOTRIENT) and PONATinib (ICLUSIG) (10) Two new oral chemotherapy agents have names that may cause confusion: pazopanib and ponatinib. Tablet strengths and dosages are different, which may help prevent an
23、d detect errors. Computer systems that list oral chemotherapy linked to available dosage strengths will help to minimize the potential for error, as will listing appropriate dosing information for labeled indications. The use of tall man lettering with the unique letter characters differentiated (PO
24、NATinib and PAZOPanib) can also be helpful. IV administration of oral liquid niMODipine(11)The drug niMODipine is often given via a nasogastric tube. Unless pharmacy prepares the liquid and dispenses it in an oral syringe, nurses have to extract the product from the gel capsule with a syringe and ne
25、edle. On at least 25 occasions, the liquid extracted from a capsule was accidentally injected IV, resulting in 5 deaths and 5 near-death events.If pharmacy does not extemporaneously prepare a liquid formulation of niMODipine from capsules and dispense the drug in oral syringes, the hospital should u
26、se a new commercial product for adults, NYMALIZE (niMODipine) oral solution (www.ismp.org/sc?id=191). This product is indicated for improvement of neurological outcomes in adults with subarachnoid hemorrhage.Independent double checks are undervalued and misused(12)The value of a manual independent d
27、ouble check has been questioned by those who rarely find mistakes. Its use has been a source of stress for busy staff. Its overuse with high-alert drugs has been called to task given its status as a weak risk-reduction strategy, particularly if its the only safeguard in place. Its inconsistent use,
28、variability with how its carried out, and the superficial manner in which many checks are conducted has rendered it less effective than anticipated. However, studies have shown that independent double checks can detect up to 95% of errors if done correctly.Evaluate the procedures for which you requi
29、re a double check, monitor compliance, assess how often the checks are conducted as designed, and then make the necessary revisions to promote effectiveness. Manual double checks are most effective when conducted independently in a cognitive manner, and when used judiciously for selective high-risk
30、tasks or high-alert medications. Avoid sole reliance on double checks as a safety strategy. Fewer double checks strategically placed at the most vulnerable points of the medication use process will be much more effective.Mix-ups between nalBUPHine and nalOXone(7) Three patients received nalbuphine i
31、nstead of naloxone. One event involved the accidental selection of nalbuphine, which appeared immediately before naloxone on an automated dispensing cabinet (ADC) screen; another involved an ADC stocking error. The third error involved selection of the wrong product from an anesthesia tray. Tall man
32、 lettering on ADC screens and pharmacy labels may help avoid mix-ups, as well as adding the words “rescue agent” next to nalOXone entries, if space permits. Locked lidded drawers for nalBUPHine and nalOXone could also prevent inadvertent selection of the wrong drug. 10-fold overdoses of IV acetamino
33、phen(9)British and Spanish authorities have analyzed 52 overdoses of IV acetaminophen in children younger than 1 year. Recently in the US, acetaminophen IV 250 mg was prescribed for a 25 kg child. A mental slip led the clinician to program an infusion pump to deliver 250 mL (2,500 mg) instead of 250
34、 mg (25 mL). Children and low-weight adults are at greatest risk of overdoses because they need less than a full 100 mL (1 g) bottle, thus requiring a calculation to determine the volume to infuse.When prescribing the drug, include the mg per kg weight-based dose along with the total calculated dose
35、. For the product label and medication administration record, include both the mg dose and volume to be infused. Pharmacists should prepare pediatric doses of 600 mg or less in a syringe, and nurses should administer the drug via a “smart” syringe pump with dose limits active in the drug library. Fo
36、r adult infusions, smart pump use is also advised. Saline flush administered via ON-Q C-bloc during attempt to collect blood from central venous access device (CVAD)(10)A laboratory technician who was attempting to collect blood from what she thought was a CVAD instead administered a saline flush vi
37、a a yellow-striped extension tubing connected to an ON-Q C-bloc continuous peripheral nerve block infusion. The ON-Q system catheter was anchored to the front of the patients shoulder, and the upper part of the gown obscured the ON-Q system. A blue connector was visible and thought to be attached to
38、 the CVAD. Limit access to CVAD lines to those with professional training. Promote a consistent process for tracing all catheters/lines from the access site to an infusion or capped access port before drawing blood, connecting tubing, or administering drugs or solutions. Affix labels on lines if the
39、 patient has more than one port of entry into the body. Starter doses from the emergency department (ED) may not be dispensed in child-resistant containers(12)EDs and physician practices often send patients home with drug samples or starter doses in unit dose packages. These packages may not be chil
40、d resistant. If dispensed in plastic bags or envelopes, the medications may be easily accessed by children, especially if set down on a counter upon arriving home from the ED. Organizations that dispense drug samples or starter doses should evaluate their practices and modify their procedures as nee
41、ded to ensure the safety of patients and children in their homes. With the increased number of 24-hour community pharmacies, these services may not be necessary.Mix-ups between risperiDONE and rOPINIRole(7)Last year, ISMP and FDA received more than 200 reports of mix-ups between risperiDONE and rOPI
42、NIRole, and these events have continued. In one of the latest cases, a patient experienced nausea and an unexpected sedative effect after taking what was thought to be risperiDONE. Both products were from the same manufacturer and in the same shaped bottle with similar label printing.When prescribin
43、g either drug, the purpose of the drug should be included with the order, and pharmacists and nurses should verify that the therapy matches the patients condition. In pharmacies, the products should not be stored near each other, and tall man lettering should be used for storage, labeling, and computer listings.
