From Mr T. Delaney, MPSI
SIR,—I fully agree with Mr Monk (PJ, November 13, p785), writing in response to my letter on colouring of packages (PJ, October 30, p708) that the ideal solution to the problem of inadvertent use of undiluted potassium concentrates is to remove them altogether. At this hospital, we have introduced a policy of using commercially available potassium infusions as the preferred option on most wards. However, as he rightly points out, there are some areas, such as intensive care and paediatrics, where commercially available products will not suffice. We have a state of the art aseptic unit in our hospital, and we have sent a business plan to management to facilitate the introduction of a potassium centralised intravenous additive service to meet those departments with special needs.
Our aseptic service operates only 35 hours per week at present. This is a serious barrier to provision of the extensive services to which Mr Monk refers. Without a round-the-clock service, it is inevitable that we must make provision for some small degree of ward-based preparation of potassium infusions. To this end, our risk management approach is to allow small quantities of the concentrate ampoules to be stored at ward level, and only in the narcotics cabinet. We use coloured labels because these further reduce risk by making the potassium concentrate more recognisable. It is a simple matter to audit the usage of the concentrates and determine whether their use was justified on each occasion, or whether a commercially available preparation would have sufficed.
Mr Monk suggests that a centralised intravenous antibiotic preparation system would have prevented our lignocaine error. However, in this situation, the doctor in question prepared the dose because his senior colleague took a quick decision to administer a dose of gentamicin towards the end of a long surgical procedure. The dose prescribed was an individualised one, on a weight-based calculation. Our aseptic unit, located in the pharmacy, could not have responded sufficiently quickly to a stat order for this antibiotic, even if we were offering the service. We would have needed to have a satellite aseptic unit, based in the operating theatre, to respond to this request. Mr Monk's logic holds true, and the episode could be used to make a case for funding of a satellite service in the operating theatre.
At that point, the next barriers to be overcome would be the shortage of available staff to work in such units in this country. Until these barriers are overcome, the more practicable measures - using more easily distinguishable ampoules, storing them separately, and improving the training of junior doctors in relation to safety checking systems - will continue to be valuable and worthwhile.
In Ireland, as in the United Kingdom, we also have many hospital pharmacies which do not have centralised intravenous additive services. Contrary to what Mr Monk may believe, I consider that this service deficit is not the result of nonchalance among hospital pharmacists. There are many other reasons for the current state of affairs in Ireland, and I suspect that some of these hold true in the United Kingdom.
In Ireland, the absence of a hospital CIVA service is strongly correlated with insufficient investment by hospital management in education, training, facilities and equipment. It is also strongly associated with serious difficulties with the hiring of suitably qualified staff to manage and operate these facilities. A recent survey by our national Hospital Pharmacists' Association showed that 15 per cent of hospital pharmacist posts nationally are vacant.
There is a major issue of inequity of funding between large teaching hospital pharmacy departments in the big cities, and smaller hospitals in country towns. The Hospital Pharmacists' Association survey also showed that, of 187.5 whole time equivalent posts approved by government in our public hospitals, 85.5 of these posts were located in just seven large teaching hospitals. These hospitals cater for one million of our citizens. The other three million are catered for by only a few additional pharmacists.
Poor staffing levels beget poor quality of work life, and exacerbate the problem of recruitment. The graduates of today have high expectations of their jobs, and are not willing to work in conditions which do not permit them to utilise their expertise or develop professionally.
When hospital pharmacists work in settings where technician support is minimal and pharmacist-to-bed ratios are as high as 1 to 250, the mention of CIVA services is greeted with incredulity. Perhaps one approach to correcting this problem is, as Mr Monk suggests, to use the risk management philosophy to support the argument for development of comprehensive pharmaceutical services.
Tim Delaney Head of Pharmacy, The Adelaide & Meath Hospital, Tallaght, Dublin 24, Ireland