SAFE MEDICATION PRACTICES IN HOSPITAL...

This presentation outlines about various possibilities of medication errors, stratergies to overcome it, High Alert Medicines and safe medication handling practices

1. SAFE MEDICATION PRACTICE DR. AHANA HAROON CLINICAL PHARMACIST

2. MEDICATION ERROR Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional or patient

3. FACTORS LEADING TO MEDICATION ERROR

4. TYPES OF MEDICATION ADMINISTRATION ERRORS DRUG DOSE ROUTE TIME PATIENT The 5’R…

5. RIGHT PATIENT RIGHT DRUG RIGHT DOSE RIGHT ROUTE RIGHT TIME Always check patients ID BAND prior to drug administration Check for any drug allergy present Perform a triple check of drug label. (retrieving, preparing, administering ) Never administer medicine prepared by another person & drug that is not labelled Check label for medicine concentration Triple all drug calculation Compare prepared dose with medication order Verify drug route with order before administering Should be administered only via the route specified in order Verify medicine schedule with order (date, time) Check last dose of drug given to patient Administer within 30 mins of schedule Always follow the 5’R…

6. POSSIBLE ADMINISTRATION ERRORS Failure to check drug allergy and own medicines Errors due to LASA medicines Crushing “DO NOT CRUSH” tablets Y site incompatibility Errors with vasoactive agents (Uncontrolled administration) Tubing/ catheter misconnection Side puncturing (Air embolism, Contamination) Improper dilution Multi vial issues

7. REMEMBER… Clarify prescription, if having any doubts Be knowledgeable about the drug you administer Keep the narcotics under double lock If cloudy or precipitated ampoule/ vial return to pharmacy Ensure safety of high alert medicines Stay with patient until he takes the medicine Report all medication errors for prevention of future occurrence

8. HOW TO FILL A MEDICATION CHART Write the name of each medicine. It may have two names–a brand name ( eg - TYLENOL) and a generic name ( eg - ACETAMINOPHEN). Both names has to be written in capital letters. Write the strength of the medicine ( eg - 20 mg). Write the instructions for taking the medicine–when, how, and how much. Include special instructions, such as whether to take it with food. Write the amount of medicine you take for each time of day–morning, noon, evening, bedtime. Handwriting must be legible

9. Administer medicine exactly 1 hr apart if prescribed Q1h – 24 times a day 2 hrs apart if prescribed Q2h- 12 times a day 3 hrs apart if prescribed Q3h – 8 times a day 4 hrs apart if prescribed Q4h – 6 times a day 6 hrs apart if prescribed Q6h – 4 times a day 8 hrs apart if prescribed TDS – 3 times a day 12hrs apart if prescribed BD – 2 times a day 24 hrs apart if prescribed OD – 1 time a day

10. HIGH ALERT MEDICINE These are drugs that bear a heightened risk of causing significant patient harm when they are used in error Consequences of error are more devastating to patients Usually they have narrow therapeutic index Must be double checked by 2 individuals before administration

11. MONITORING OF HIGH ALERT MEDICINE SL.NO CATEGORY OF MEDICINE MONITORING POINTS 1 Adrenergic agonist, IV BP- vasoconstriction/ dilation? HR- bradycardia/ hypotension? 2 Adrenergic antagonist, IV 3 Anesthetic agents, general, inhaled, IV HR/ BP/ SPO2/ ECG 4 Anti arrhythmics , IV B/f induction- Apical pulse rate, rhythm At induction/ at dose change- C ardiac rate, rhythm continuously Vital signs 5 Anti thrombotics Anti coagulants- APTT/ PT/ CBC/ bleeding/ HIT Thrombolytics - vital signs/ neurological status/ BP< 185/110 mmHg 6 Cardioplegic solution PERFUSIONIST 7 Chemotherapeutics- IV/PO BSA- Patient height, weight (For DOSE CALCULATION) Before chemo- ANC/ CBC/ LFT During chemo- Vitals- PR/ HR/ BP/ SPO2/ RR After chemo- SE

12. SL.NO CATEGORY OF MEDICINE MONITORING POINTS 8 Dextrose hypertonic > 20% Vitals Edema ?- S. sodium level Hypervolemia ?- Elevated BP/ Breathing difficulty Blood and urine sugar level 9 Dialysis solution- HD and peritoneal S. Electrolyte level RFT- BUN, S.Cr CBC- Hb , Hematocrit Pre/post HD- patient weight, BP- fluid overload? Catheter placement? 10 Epidural/ intrathecal medicine Clinical observation to be continued until EPIDURAL cease HOURLY sedation/ HR/ RR/ Pain score 4 th hourly- BP/ Temp 1 1 Inotropes Arterial BP monitoring Central line ECG/ vitals/ Cardiac monitoring/ Urine O/P ? 12 Insulin Blood G lucose level Activity level Urinalysis- glycosuria ?

13. SL.NO CATEGORY OF MEDICINE MONITORING POINTS 13 Moderate sedatives B/F induction- Vitals- BP/HR/ RR PR- every 5 mins in deep sedation, every 15 mins in moderate sedation Level of consciousness, Patient response 14 Opiods Respiratory distress- breathing/ oxygenation? O2 saturation. <89%- W/H opiods Drowsiness? 15 Neuromuscular blockers Patient fully ventilated? Vitals- RR/ HR/ BP/ O2 saturation 16 Parenteral nutrition I/O chart 12 th hourly Dehydration/ overhydration ?- S. electrolytes level- daily Na, K, HCO3, Ca, Cl RFT- S.Cr , BUN, LFT- S. protein Hypo/ hyperglycemia- blood sugar 8 th hourly 17 Sodium chloride > 0.9% conc Vitals- BP/RR Edema/ fluid status- S.Cl level, S.Na level 4 th hourly- NMT 8mEq/L rapid correction in 24 hrs Rapid rehydration – cerebral edema

14. SL.NO CATEGORY OF MEDICINE MONITORING POINTS 18 Sterile water for injection, inhalation and irrigation >100ml Local tenderness Phlebitis Extravasation- tissue necrosis 19 Sulphonyl urea OHA Blood glucose level Urinalysis- glycosuria RFT/ LFT 20 Potassium chloride ECG monitoring Arrhythmia Electrolyte level 21 Sodium bicarbonate Cardiac rhythm

15. SAFE HANDLING OF HIGH ALERT MEDICINE List of high alert medications used within the facility shall be identified. List of high alert medications shall be disseminated to all healthcare personnel in the facility. High alert medications should have labels on storage shelves, containers, product packages OR loose vials/ ampoules. Use either HAM sticker/label Review and evaluate the checklist for high alert medications in Medication Safety Self – Assessment Form. High alert medications will be prescribed, dispensed, and administered using safe practice .

16. HIGH ALERT MEDICATION LABEL

17. KNOW ABOUT

18. Y SITE INCOMPATIBILITY

19. ERRORS WITH VASOACTIVE AGENTS Not providing dedicated lumen for administration of vasoactive agents leading to rapid flush and arrythmias . Interrupted administration of vasoactive agents (Adrenaline, Nor adrenaline). Failure to detect extravasation. Use syringe pump or infusion pump for precise delivery.

20. DOUBLE PUMPING Commence doubling pumping (syringe change) when there is at least 30 minutes OR 5 mL of the infusion remaining (whichever occurs first). Turn three way tap so both syringes are ‘on’ to the patient. Start the new syringe at half the infusion rate, leaving the current syringe on current rate. Monitor arterial blood pressure closely for a rise of up to, but no more than 20mmHg in systolic blood pressure. This indicates the new syringe has reached an adequate pressure and is administering the drug to the patient. Immediately increase new syringe to full rate, whilst decreasing the original syringe to half the original rate. Wean or turn old syringe off as indicated by systolic blood pressure. Once the patient has recovered from the double pumping procedure, turn the three-way tap ‘off’ to the empty syringe, replace this syringe with a new syringe. This tap should remain ‘off’ to the secondary syringe when not in use.

21. Errors related to Concentrated electrolytes/ High Risk Medications Many concentrated electrolytes are colourless look alike- can be mistaken for other drugs. (Look Alike) Non standardised dilution leading to error Eg . 20 mEq KCL in 1000 ml diluent versus 20 mEq in 100 ml diluent. Same drug different concentration – Heparin 20000 units per ml versus 40000 units per ml. Improper dilution leading to chemical phlebitis The concentration of potassium for intravenous administration via a peripheral line should not exceed 40mmol/L, as higher strengths can cause phlebitis and pain

22. LOOK ALIKE DRUGS

23. SOUND ALIKE DRUGS

24. MULTI VIAL POLICY Limit to a single person as much as possible. If NOT store safely as per manufacturer’s recommendations. Follow infection control practises (disinfect top of the vial). If not punctured, discard as per manufacturer’s recommendation. If punctured , discard as per institutional policy ( eg . 28 days - United States Pharmacopeia ) or as earlier if manufacturer recommends.