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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

Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

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Page 1: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

Patient SafetyWHO 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

Page 2: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

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

Page 3: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

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

Page 4: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

Identified Conc Injectables

• 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.

Page 5: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

Identify all types & location of CIs

Standardize and limit the number of concentrations

Procure suitable premix bags

Is there still a valid clinical need for CIs ?

Yes

Determine minimum amount CIs for safe care.

Identify secure and segregated storage of CIs

Ensure Smart pump profile & Policies/ Procedures current

No

Remove CIs from these clinical areas

Procure additional premix bags and set stock levels

Procure additional premix bags

and set stock levels

Ensure Smart pump profile & Policies/ Procedures current

Ensure Smart pump profile & Policies/ Procedures current

Train authorised staff to access and use CIs

Monitor usage of premix bags annually

Monitor usage of Premix bags annually

Evaluate CIs usage and clinical need annually

Process Flow used for Managing Concentrated Injectable Medicines

Page 6: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

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)

Page 7: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

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 at33mls an hour. Checked the infusion with RN. I went to give the infusion and as soonas it started patient 7 years old began to yell out in pain. I stopped theinfusion immediately and when I checked the pump it read volumeinfused zero mls. The IV line was patent and there was no redness atThe site. I discussed this with Dr and Mum requested it be dilutedfurther.The doctor recharted the transfusion to 200mls 0.9% Saline bag with14mmol of KCl. I again checked this with RN. The infusion was taken tothe bedside and commenced. Again child began to yell out in pain and Istopped the infusion immediately and when I checked the pump it readvolume infused zero mls. The IV line was checked and it was patent andthere was no redness at the site.

I then discussed with Dr , who re charted0.45%NaCl + 2.5%Dex 500ml bag with20mmol KCl. Mum requested that theinfusion start at 30mls an hour, patienttolerated this reporting no pain and therewas no redness at site, after approximatelyone minute Mum requested the infusionrate increase to 60mls an hour, this wasalso pain free. Mum then asked if the rateincreased to 90mls/hour as charted. Thiswas well tolerated and there were nofurther concerns.

06-Mar-09 Pt charted KPO4 20mmol x2 via peripheral line. Nurse identified withH/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 to70mls/hr & Dr advised.

Further information from patient’s chart LH9/3/09 : Was on D5W at 70mls per hourthen bloods showed low K+ and lowPhosphate. Charted and made up40mmol/1 lit D5W and given at500mls/hour (outside of Protocol andstanding order guidelines) until noticed andstopped by second nurse.

04/06/09 FWD8655 M 63Y, Othapedic Surgery. Pt. arrived in Recovery @1948after 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

Page 8: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

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.

Page 9: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

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)

Page 10: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

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.

Page 11: Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical

From this to this!

The Productive Ward