Hospital Pharmacist
2007;14:349-350
November 2007

B Braun

Safer use of intravenous drugs — new solutions for old problems

The impetus of life-long disability fuels her passion for helping others to avoid medication errors, Miriam Klein, medication safety fellow at Kingsbrook Jewish Medical Center, New York, told the audience. She has been profoundly deaf since infancy when she received an overdose of an unnamed antibiotic.

After qualifying as a pharmacist Dr Klein studied for a doctor of pharmacy degree, with the aim of working to prevent medication errors. She is now responsible for promoting improvements in medication safety in relation to the labelling of injectable vials and ampoules.

Peri-operative risks

The 2007 MedMarx data report, which examined peri-operative medication error records in the US over a seven-year period, showed that 7.3 per cent of errors occurring in the operating theatre resulted in harm to patients.

This was significantly higher than in other peri-operative areas. Administrating injections from unlabelled syringes was believed to be a major contributory factor.

A 2006 report from the Institute of Medicine in America analysed 32,000 errors arising from “look-alike, sound-alike” drug names. Labelling and packaging issues accounted for 33 per cent of all errors and 30 per cent of all fatalities.

Dr Klein noted that one goal of the Joint Commission (the body responsible for accrediting health care organisations in the US) for 2008 is the improvement of medication safety. The proposed solutions include labelling all medicines and medicine containers such as syringes and medicine cups.

Many organisations will find this requirement difficult to comply with, however: “Pharmaceutical firms must step up to take a collaborative role in providing safer labelling options,” she said.

Dr Klein does not believe that premixed, ready-to-use injections will be the complete solution to the problem, because of insufficient storage space on hospital wards.

Transferable syringe labels

In Germany, most injectable medicines now have transferable (peelable) labels that can be transferred to the syringe. This provides the doctor or nurse with essential information at the time of administration.

A symbol to indicate that the product is a high-alert medicine can also be incorporated onto the transferable label.

Dr Klein is currently working in collaboration with the National Patient Safety Agency and several UK pharmacists. She described how a label for atracurium injection has been redesigned to allow its transfer from the vial to the syringe when the product is drawn up.

This label contains dosing information, the total dose and volume, a high-alert symbol and space to write the expiry time and operator identity. The dosing information allows the person administering the medicine to make a second check at the moment of use.

High risk ward practices

“Take the ideals of pharmacy closer to the patient — that’s how to deliver safer health care,” according to Tom Gray, chief pharmacist at Derby Hospitals NHS Foundation Trust. Describing how safe practices for IV medicines could be introduced, he emphasised the importance of finding out about local practice.

“The NPSA alert [on injectable medicines, Hospital Pharmacist 2007;14:107] has galvanised us to get out and see what is happening,” he said.

A recent study compared the preparation of injections on hospital wards in the UK, Denmark and France. The results showed very different practices. Nurses in the UK did not wash their hands or swab vials with alcohol before preparing IV medicines. They were also more likely to administer the drug at the wrong rate compared to their Danish and French counterparts.

The ward environment is fraught with risk. Medicines are often stored in refrigerators alongside sandwiches and expired products, and this problem is compounded when labels are not applied. Administration is the highest risk activity in the medication process, yet has fewest opportunities for intervention. Even the “second check” may not be effective if the procedure is poor, said Mr Gray.

Increased responsibility

Intravenous injections should be prepared in the pharmacy provided the required standards can be met, and outsourced if they cannot, Mr Gray said. Furthermore, regardless of the method of preparation, pharmacy input should not stop at the pharmacy door.

Clinical pharmacists should be engaged with the product and be responsible for medicines management at ward level, he suggested. However he conceded that ward preparation of intravenous doses is often the reality and more responsive to patient need.

In Derby Hospitals NHS Foundation Trust, intravenous administration devices have been standardised, reducing the number of different devices used from 40 to five. Smart pumps with drug libraries and activity logs have been introduced and a central equipment library has been established.

Since these introductions, complaints relating to the availability of equipment have fallen from 250 in a year to fewer than 10 in the following year. The number of devices has remained constant but they are used more efficiently, he noted. They are also serviced and cleaned on a regular basis.

The new hospital in Derby has been designed with satellite pharmacies on every floor. Each one contains facilities for dispensing injectable medicines that have been built to licensing standards. Pneumatic tubes currently link the pharmacy to the wards, although future electronic links to the pharmacy dispensing robot are anticipated.

The plan is to integrate multi-skilled pharmacy teams to undertake both clinical and aseptic work. “Everything will be done at satellite level, near the patient”, said Mr Gray.

Safe paediatric practice

Steve Tomlin, principal paediatric pharmacist at Guy’s and St Thomas’ NHS Foundation Trust, London, explained that small differences have a big impact on paediatric patients. For example, if a 0.5kg neonate is weighed while wearing a wet nappy, its weight could greatly increase compared with when the nappy was dry.

An estimated 1,675 medication errors affect paediatric inpatients in the UK each year, and 85 of these are likely to be moderate or severe. The real numbers are probably higher, but there is reluctance to report errors involving unlicensed products, which are widely used in paediatrics.

A study conducted in Glasgow showed that the error rate was higher in intensive care, especially involving younger children — 20 per cent occurred in patients aged under one month. IV dose administration was involved in 56 per cent of errors.

Part of the problem is that medicines are designed for adults and manufactured in standard dose units. In children, every dose is different and problems arise when decimal points are applied. Mr Tomlin recently examined the injection stocks in the neonatal intensive care unit at St Thomas’ Hospital, and compared the quantities in each vial with the usual doses.

He found that 31 per cent of prescribing orders required a dose amounting to less than one tenth of the contents of one vial. Nearly 5 per cent required less than one hundredth of the contents of one vial, creating a huge potential for error.

Mr Tomlin explained that if an overdose of a particular medicine required the contents of several vials to be administered, mental alarm bells would start to ring. However, if a 100-fold overdose is available in a single vial, there is no such alarm.

Neonate intravenous risk

Intravenous administration in neonates is fraught with problems, especially extravasation. “You need to know your drugs and have policies for management,” said Mr Tomlin. Issues of stability and concentration are also important. Insulin can stick to plastic tubing and syringes, and effectively reduce the dose administered.

Many paediatric units now pretreat syringes with insulin or co-administer albumin to minimise this effect.

IV fluids present further risks for neonates. If injections are diluted there is a risk of fluid overload because pre-term neonates have a circulating volume of about 80ml. Saline flushes can quickly deliver large amounts of sodium and the use of hypotonic fluids is questionable.

With regards to managing the risks of IV treatment in children and neonates, Mr Tomlin suggested that dose-banding (preparing one syringe to use for a range of doses) and premixed injections might be feasible for young children, but less so for neonates. Standard procedures would aid risk management, as would ensuring quiet areas for working and electronic prescribing.

In summary, Mr Tomlin said that many issues in paediatrics are the same as in adult medicines but sometimes the solutions to problems involve moving in a different direction.