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FIGURE 64-16 · A basic intravenous (IV) setup includes tubing to deliver basic IV fluids via the client’s venous access. Following the physician’s order and using a second infusion bottle or bag, the pharmacist adds medication to a predetermined volume (usually, 50 or 100 mL) of a compatible IV solution.
The controller or pump can be programmed to deliver the volume contained in the secondary bag. Nursing Alert If a pump or controller is not used, the drip rate must be calculated (see Box 64-2). Key Concept Do not refer to a medication as an IV push if it is to be given over a period of time.
FIGURE 64-18 · The nurse will often be expected to gather materials and equipment for venipuncture (phlebotomy).
Venipuncture or phlebotomy is the process of puncturing a vein for the purpose of obtaining a blood specimen (“drawing blood”) or establishing an intravenous access site (Fig. A blood specimen can also be obtained by a skin puncture (capillary puncture), as in blood sugar testing for persons with diabetes.
For a catastrophic error to occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting in an error. These medications are used in emergency departments, intensive care units, interventional radiology areas, and even medical and surgical units. Gaunt, PharmD Senior Patient Safety Analyst Pennsylvania Patient Safety Authority ABSTRACTWhen pharmaceutical services are not available, the medication-use process can be more vulnerable to errors. Keywords: medication errors, medication errors nursing, medication errors canada, medication errors cno, medication errors in nursing canada, medication errors canada statistics, medication errors in pharmacy, medication errors in nursing homes, medication errors statistics 2015, medication errors in nursing ppt, medication errors may be common after hospital discharge . Also shown are the access port on the tubing, used for injection of small amounts of medication by syringe (below) and the access port used for piggyback administration of larger amounts of medication (above). This smaller infusion, which contains medication, commonly an antibiotic, is referred to as the secondary infusion, superimposed infusion, or IVPB. When the total contents of the secondary bag have been administered to the client, the controller or pump automatically switches back to the primary infusion bag. In this case, identify the procedure as "an IV to be given over 5 minutes or over 10 minutes,” for example. Some of the items needed to obtain a blood specimen are shown here (clockwise, from bottom left): tourniquet, Vacutainer (vacuum) blood tubes, safety syringe with needle, alcohol sponges, and gloves. It consists of a disposable plastic sleeve into which a double-ended needle setup is inserted. In addition, an arterial puncture can be performed to obtain values, such as blood gas analysis. In addition to the butterfly needle, two types of intracatheters are commonly used, allowing fluid to flow through a flexible catheter into the vein. If the layers are set up with all the holes lined up, this is an inherently flawed system that will allow a problem at the beginning to progress all the way through to adversely affect the outcome.
NMBAs render patients unable to move or breathe and are considered high-alert drugs because misuse can lead to catastrophic injuries or death, especially when administered to patients who are not properly ventilated.
Between June 2004 and September 2010, Pennsylvania hospitals submitted to the Pennsylvania Patient Safety Authority 519 medication error reports that implied an event occurred while the pharmacy department was closed.
This method of administration is referred to as “IV piggyback” (IVPB) or a superimposed infusion. The IVPB is connected to the primary infusion by way of secondary tubing and a needle or needleless setup.
The secondary bag must be hung higher than the primary bag to allow a greater force of gravity to act on the secondary solution. This bag is hung on an IV pole and a volume-control device, such as the Buretrol, is hung below it.
This pump is able to identify dosing limits and has other safeguards to protect the client. Shown also is a butterfly needle pack with a needleless Vacutainer adaptor; used to puncture a Vacutainer blood tube. This device has a needleless connector on one end and a venipuncture needle on the other end.
It is up to the nurse to reassure the client and make him or her as comfortable as possible. Between June 2004 and March 2009, Pennsylvania healthcare facilities submitted 154 event reports that mentioned medication errors involving the use of NMBAs. The most common types of medication errors reported included wrong-drug events, drug omissions, and prescription or refill delays. It may also be called a small-volume parenteral delivery system, a partial fill, or a minibottle.
In Practice: Nursing Procedure 64-10 describes the process of piggyback administration of medications.
After priming the tubing, the ordered amount of diluent is run into the volume-control chamber (usually from 25-250 mL). Also needed are 2 X 2 gauze squares and tape or a Band-Aid, identification stickers, and a red biohazard bag.
The blood specimen can yield valuable information regarding the client’s nutritional, metabolic, hematologic, immune, and biochemical status.
The needleless end is screwed into the plastic sleeve, with the needle outward and the needleless access device inside the sleeve. The predominant medications associated with these reports were warfarin sodium, hydration solutions, insulin, guaiFENesin, and vancomycin. Many facilities have firm policies regarding which medications may be given by IV push,because the push introduces a concentrated dose of medication directly into the circulatory system. The needle end for blood drawing often contains an articulated shield, which is pushed over the needle after the venipuncture (see Fig. Both of these devices today have a locking guard mechanism that locks the needle guard in place, to prevent needle sticks when the catheter is in place and when it is removed. An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught.
Further analysis showed that 47.4% of the intended medications were not NMBAs, including cases in which the patient was harmed. The incorrect drug was retrieved from an automated dispensing cabinet or night cabinet in 82.3% (n = 130) of wrong-drug events.
This procedure is presented in In Practice: Nursing Procedure 64-12, although it is highly recommended that the nurse receive specific inservice education before performing the procedure. Strategies to address these problems include limiting access to NMBAs, segregating NMBAs from other medications, sequestering and affixing warning labels to vials of NMBAs stocked in the pharmacy, and requiring independent double checks before dispensing and administering NMBAs.
In 28.7% (n = 43) of drug omission events, the medication was not available to the nurse to administer, leading to an omission.
Neuromuscular blocking agents (NMBAs) are commonly used to relax skeletal muscles during surgery conducted under general anesthesia. Strategies to prevent errors when the pharmacy is closed include providing access to a limited supply of medications to be used for urgent medication orders, standardizing processes for accessing medications when the pharmacy is closed to reduce variability and opportunity for error, and establishing a forcing function error reduction strategy to make the allergy “reaction” selection a mandatory entry in the organization’s order entry systems for prescribers and pharmacists. This type of pump is able to identify dosing limits and other factors to aid in safe administration (Fig. These agents are also used in emergency departments (EDs), intensive care units (ICUs), interventional radiology areas, and even medical and surgical units for patients requiring intubation for airway management.1NMBAs produce their effect at the neuromuscular junction by interacting with acetylcholine either by depolarizing the motor end plate or by competing with acetylcholine for binding sites on the motor end plate. IntroductionPharmacists play a vital role in ensuring safe and effective medication use by reviewing medication orders before patients receive the prescribed therapy. One disadvantage of the Vacutainer needle with the articulated shield is that this system contains a large needle, which might not be appropriate for some venipunctures.
However, because of the limited hours of pharmaceutical services in some hospitals, not all medication orders are prospectively reviewed by a pharmacist.
In Practice: Nursing Procedure 64-11 describes and illustrates the process of using the volume-controlled administration setup.
When combined with a sensitivity test, it can identify specific antibiotics or other drugs to combat offending pathogens.
It is crucial for healthcare practitioners to remember that NMBAs do not affect a patient’s level of consciousness, pain, or anxiety.
This also varies significantly by staffed-bed size, with larger hospitals more likely to provide 24-hour inpatient pharmaceutical services.
After the vein is accessed by any method, the needleless connector is pushed into a Vacutainer (vacuum) tube, which draws the blood into the tube. These medications simply render the patient unable to move or breathe.2 NMBAs are considered high-alert drugs because misuse can lead to catastrophic injuries or death, especially when they are erroneously given to patients who are not properly ventilated. The other hospitals (16.7%) using off-site pharmacist review of orders had on-call pharmacists for this activity.
Provision of on-site 24-hour pharmaceutical services contributes to a more secure drug storage and distribution system. Reports Involving Neuromuscular Blocking Agents Grouped by Harm Score (N = 154) Analysis of the reported ages of the patient involved in medication errors with NMBAs reveals that more than 17% (n = 27) of the reports involved pediatric patients (see Table 2).
It also reduces the need for night cabinets, non-pharmacist access to the pharmacy, and access to medications stored in automated dispensing cabinets (ADCs) without prior order review by a pharmacist.
When the pharmacy is closed, a well-organized drug storage system can safeguard access to medications and thereby reduce the risk of medication errors or minimize adverse outcomes should an error occur.3,4 Without safeguards in place, medication errors can occur, some with tragic outcomes,5 especially if non-pharmacists have complete access to the pharmacy after hours.
During case-by-case analysis of events reported by Pennsylvania healthcare facilities to the Pennsylvania Patient Safety Authority, analysts found a number of medication errors that were occurring when the pharmacy department was closed.
Patient Age Groups Associated with Reports Involving Neuromuscular Blocking Agents (N = 154) Table 3. Some of these events, such as patients receiving a medication to which they have a documented allergy, are typically intercepted when the pharmacy department is open.
This article includes examination of medication errors reported to the Authority that occurred after the pharmacy department was closed. Predominant Medication Error Event Types Associated with Neuromuscular Blocking Agents (n = 120)Wrong-Drug Errors Involving NMBAsAnalysis of Authority reports focused on the predominant event type for this class of medication, as well as potentially the most devastating: wrong-drug errors.
Strategies to reduce the risk of error are discussed.Methodology In order to categorize and retrieve reports in which reporters implied that an event occurred while the pharmacy department was closed, Authority analysts created the standardized monitor code “24h” that can be entered into the program database during case-by-case analysis. If an NMBA is given in error to a patient who is not intubated, the respiratory muscles may be paralyzed, potentially leading to serious harm or death.
This monitor code and the phrases “pharmacy closed,” “night closet,” and “after pharmacy hours” were used to query the data to identify reports, trends, contributing factors, and risk reduction strategies.Aggregate AnalysisFrom events reported from June 2004 through September 2010, analysts identified 519 medication error events that occurred when the pharmacy was closed.
A breakdown of these events by harm score, which is adapted from the National Coordinating Council for Medication Error Reporting and Preventions harm index,6 shows that nearly 87% (n = 450) of the events reached the patient (harm index = C to I). There were six cases in which the NMBA vecuronium was administered instead of the intended antibiotic cefazolin; all of these cases resulted in harm to the patient. Top Five Medication Error Event Types (430 of 519) through June 2004 through September 2010Table 2 lists the top 10 medications involved in events that occurred after the pharmacy was closed.
Four high-alert medications, drugs that bear a heightened risk of causing significant patient harm when used in error,7,8 appear in the top 10. Intended (Prescribed) Medications Involved in Wrong-Drug Medication Error Reports (n = 57) Wrong-drug medication errors reported to the Authority include the following:A patient was admitted for a planned surgery.
The anticoagulant warfarin sodium, a high-alert medication, was the most frequently reported medication (4.4%, n = 23).
While in holding area of the OR prior to surgery, anesthesia staff started an IV [intravenous] infusion and administered what they thought was midazolam [Versed®] 1.6 mg IV.
Even though only one anti-infective agent, vancomycin, appears in the first five of the listed medications, anti-infective agents as a class were most frequently involved in events (23.3%, n = 121). The patient was taken to the OR to be ventilated and monitored until patient awoke (approximately five minutes). The lack of clinical and patient details in the reports prevents definitive determination for each and every medication. Nearly 12% (n = 62) of reports did not include sufficient information in the event description to determine in which node the event originated. Table 3. The ED physician was planning to intubate the patient, and the nurse brought in the requested medications for the intubation [midazolam, fentanyl, and succinylcholine].
Node in Which the Event Originated (457 of 519) from June 2004 through September 2010 Focused Event Analysis Wrong-Drug EventsAnalysts identified wrong-drug events as the most frequently reported (30.4%, n = 158) medication error occurring after the pharmacy had closed.
This access helps reduce the risk of drug omissions and delays but provides more opportunity for errors. The incorrect drug was retrieved from an ADC or night cabinet in 82.3% (n = 130) of wrong-drug events.
The nurse picked up the syringe and administered 1 mL when she realized it was succinylcholine. Insufficient information was provided to determine if storage or how the drug names were listed on ADC screens contributed to the mix-ups. Intubation occurred earlier than planned.In the literature, other cases appear in which NMBAs have been inadvertently administered to patients who were not receiving proper ventilatory assistance. While some of those errors have occurred in the OR, most have taken place in EDs, interventional radiology departments, ICUs, and other medical, surgical, and psychiatric units.4 Contributing Factors to Wrong-Drug ErrorsMany wrong-drug errors can be attributed to one or more common contributing factors. She brought the gentamicin to the patient care unit where one nurse drew up 12.5 mL of medication from the seven vials, and another nurse gave the medication IV push to the infant. Forty-three wrong-drug events (27.2%) involved drug products available in different combination products or modified-release formulations that carry the same name with different modifiers or suffixes. An example of a storage-related event reported to the Authority is as follows:A patient had a cesarean section and a healthy baby was delivered.
Products containing the expectorant guaiFENesin (25.6%, n =11) were the most frequently involved agents in errors involving drug products available in different combination products or modified-release formulations. GuaiFENesin is available as a single-ingredient product and in various combination products. The CRNA [certified nurse anesthetist] obtained [and administered] the medication from the anesthesia kit that he thought was Ancef, but the patient developed respiratory insufficiency and the CRNA noted that he had administered vecuronium not Ancef. The patient was resuscitated, given neostigmine to reverse the respiratory paralysis, intubated, and administered oxygen. Other medications with names that have suffixes were also cited in medication error reports. It was later determined that the physician had administered the syringe containing rocuronium instead of the intended midazolam. One example involving similar manufacturer labeling, as well as storage issues, submitted to the Authority is as follows:A patient was scheduled for an open reduction internal fixation for a fracture of the left hand. For example, see the following:A patient was ordered quinine sulfate and needed the dose after the pharmacy had closed. The anesthesiologist came into the room at the time that the patient complained of being short of breath. In 28.7% (n = 43) of the reports, the medication was not available to the nurse to administer. Some reports simply noted “not available” for the reason why the medications were not available, and other responses included reasons such as the nurse being unable to locate the medication and the pharmacy not delivering the medication before it closed. The surgery procedure was completed, and the patient was extubated and taken to the postanesthesia care unit with no sequelae. A breakdown in the transcription process was noted in 16.7% (n = 25) of the drug omission reports. After the surgery was completed, a review of the trash and needle box led the anesthesiologist and the CRNA to believe that vecuronium (which was located next to Ancef in anesthesia cart) had been administered rather than Ancef (both require reconstituting and are similar shape vials).Other cases have been reported in the literature. In 19 of these reports, transcription did not take place after the original order was written or when copying from an old medication administration record (MAR) to a new MAR. For example, a number of nurses mistakenly reconstituted measles and Bacillus Calmette-Guerin vaccines with pancuronium, instead of sodium chloride, and administered the vaccines to healthy infants. For example, in 6% (n = 9) of the reports, nursing staff did not call or attempt to call the on-call pharmacist for assistance. Some examples of failure to follow after-hours procedures reported to the Authority include the following:Vancomycin protocol was ordered after pharmacy hours. The patients experienced dyspnea and respiratory depression but, fortunately, sustained no permanent injuries.7Look-alike drug names. The nurse did not follow procedure.A patient was ordered morphine PCA after the pharmacy closed. The nurse should have notified the supervisor to call the on-call pharmacist to compound the drug.Prescription or Refill Delay EventsAnalysts identified prescription or refill delays as the third-most frequently reported (11%, n = 57) type of medication event occurring after the pharmacy had closed. In follow-up to the event, labels were placed on the medication drawers indicting both the generic and brand name.Norcuron 10 mg was ordered verbally.
Similar to drug omissions, anti-infective agents (21%, n = 12) were more often involved in these events as any other class of drug. The first nurse asked another nurse to obtain the medication from the automated dispensing cabinet. The second nurse repeated back “Narcan 10 mg” and the first nurse stated, “yes.” The second nurse handed 5 x 2 mg syringes to the first nurse.
Narcan was given by the first nurse.Similar cases have been reported to ISMP involving mix-ups between the proprietary names Narcan (naloxone) and Norcuron (vecuronium).
In one case, a pharmacist misheard a verbal order and dispensed the NMBA Norcuron when the opioid antagonist Narcan 1 mg IV was ordered. The night cabinet was not properly stocked, so the pharmacist had to be called in.Prescribing EventsOne key service that the pharmacy provides is prospective medication order review.
In another case, a nurse transcribed a verbal order for Narcan as “1 amp Narcan,” but a pharmacist misread the handwritten transcription as “1 amp Norcuron.” When Norcuron was dispensed, another nurse thought Norcuron was the generic name for Narcan and administered it to the patient, who immediately stopped breathing. One aspect of order review is checking the patient’s medication and laboratory profile for wrong doses, documented allergies, and potentially serious interactions.
When pharmaceutical services are not available, either on-site or by means of remote pharmaceutical services, vulnerability is introduced into the medication-use system that can allow prescribing errors to reach patients more easily. In the third case, a physician wrote “Narcan 1 amp IV.” An ICU nurse tried to obtain the drug from an automated dispensing module where drugs were listed by their generic names. She asked a colleague, “What is the generic name for Norcuron?” When her coworker said vecuronium, she removed the NMBA from the cabinet and gave the patient an unknown quantity from the 10 mg vial. More than 62% (n = 20) involved a patient that was prescribed a medication to which he or she had a documented allergy. Only one documented allergy was caught before reaching the patient; 95% (n = 19) of events reached the patient, with one requiring additional treatment. However, the pharmacist misread the faxed copy of the handwritten order and entered vecuronium into the pharmacy computer. Examples reported to the Authority include the following:Order [was placed] for cefepime 1 gram. Fortunately, the technician had affixed a vivid alert sticker stating, “Neuromuscular blocker, patient must be intubated” to the bag, which the nurse noticed, thereby averting a serious medication error.6Unlabeled syringes. NMBAs have been accidentally administered when syringes containing the drug were either unlabeled or mislabeled.
Although Pennsylvania facilities have not submitted reports specifically mentioning unlabeled syringes with NMBAs to the Authority, one example of a mislabeled syringe is as follows:The anesthesiologist thought he was administering Versed. The patient developed a rash because he is also allergic to Rocephin®, which is also a cephalosporin.This patient is allergic to Cipro®. This patient was ordered Levaquin®, which is contraindicated in patients allergic to Cipro. The patient was unable to speak for three to five minutes, and the anesthesiologist recognized that the wrong drug was given to the patient.
The medication was removed from the night room by the nursing supervisor while the pharmacy was closed.Anti-infective agents, including levofloxacin, cephalexin, and azithromycin, were involved in over half (n = 11) of the documented allergy events. This was reversed and the patient responded without any problemOne example of an unlabeled-syringe-related error reported in the literature occurred in an ED. Celecoxib, ketorolac, and other analgesics accounted for another 20% (n = 5) of these events.
Commercially prefilled saline flush syringes were not available, so nurses prepared a supply of syringes each day from multidose vials.
Risk Reduction StrategiesHealthcare facilities can strive to identify systems-based causes of the medication errors that take place when on-site pharmacy services are not available and implement effective risk reduction strategies to prevent harm to patients.
Although many of the reports submitted to the Authority did not explicitly reveal all of the causes and contributing factors, healthcare facilities may consider the strategies described below, which are based on a review of events reported to the Authority, observations from the Institute for Safe Medication Practices, and recommendations in the literature.Pharmaceutical ServicesExplore the possibility of establishing on-site 24-hour pharmaceutical services. Health-system pharmacies have an obligation to review medication orders for appropriateness and safety.
The syringe containing vecuronium was later used to flush the IV line of an alert three-year-old child. Develop protocols or checklists to guide the practitioner as to when a supervisor or pharmacist should be contacted to assist in medication retrieval and preparation. Allow floor stock of these agents only in the OR, ED, and critical care units where patients can be properly ventilated and monitored.Segregate storage. When NMBAs must be available as floor stock, have pharmacy assemble the vials in a distinct, sealed box with warnings affixed as noted below. The predominant types of medication errors identified through analysis of the event descriptions are wrong-drug errors, drug omissions, and prescription or refill delay events. Prescribing errors primarily involved the ordering of medications to which the patient was allergic.
The primary long-term goal to prevent errors when the pharmacy is closed is to explore the possibility of establishing on-site 24-hour pharmaceutical services or remote, or off-site, pharmacy order entry services. Regular monitoring of medication retrieval when pharmacy services are unavailable could unveil potential errors.
Employment of strategies to safeguard the storage and access of drugs can help prevent errors and harm to patients.NotesPedersen CA, Schneider PJ, Scheckelhoff DJ. Include the need for ventilation support during and after administration as well as a protocol that stipulates automatic discontinuation of these agents after extubation and removal from a ventilator. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient edication-2009.
Build alerts in the pharmacy computer to verify the patient’s location when NMBAs are entered.
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration-2008. If the patient is not in a critical care unit, ED, OR, or invasive procedure area, question the order and verify ventilatory assistance before dispensing the drug. If possible, establish computerized crosschecking of the patient’s location when entering NMBAs.
Consider an independent double check of these medications before dispensing and administering.
Ensure the medication is checked against the original order.Supervision during initial administration.
Require bedside attendance of a licensed practitioner who has experience with intubation and airway management during initial administration of an NMBA.Prompt removal of discontinued products.
Place vials, bags, and syringes of NMBAs in a sequestered bin for immediate pharmacy pickup after the patient has been extubated or the drug has been discontinued.Increase awareness. Orders should not be written “prn for agitation” but more specifically as part of an intubation procedure or to maintain a specific level of paralysis while the patient is on a ventilator only. ISMP 2007 survey on high-alert medications: differences between nursing and pharmacy perspectives still prevalent. Remote order entry services: providing 24-hour pharmaceutical care for small to medium sized hospitals. Improving the safety of neuromuscular blocking agents: a statement from the USP Safe Medication Use Expert Committee.
Self Assessment Questions The following questions about this article may be useful for internal education and assessment. They should only be administered by staff with experience in maintaining an adequate airway and respiratory support. They are often used in emergency departments, intensive care units, and interventional radiology areas.
They interact with acetylcholine to prevent motor transmission, which then prevents patient movement.The most commonly reported type of medication error event types associated with NMBAs are ___________. Limit access to NMBAs by only storing them in care areas where patients can be properly ventilated and monitored.
Build alerts in the pharmacy computer to verify the patient’s location when NMBAs are entered.A patient had a cesarean section and a healthy baby was delivered. The certified registered nurse anesthetist (CRNA) obtained and administered a medication from the anesthesia kit that he thought was Ancef. The patient developed respiratory insufficiency, and the CRNA noted that he had administered vecuronium, a NMBA, not Ancef. Require an independent double check of NMBAs when retrieving and before administering the medication. The patient’s nurse asked the nurse supervisor to retrieve the medication from the hospital’s night stock.
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