Medication Safety Practices in Perianesthesia Care Jennifer Watson, PharmD Medication Safety...

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Transcript of Medication Safety Practices in Perianesthesia Care Jennifer Watson, PharmD Medication Safety...

  • Medication Safety Practices in Perianesthesia CareJennifer Watson, PharmDMedication Safety PharmacistCentracare St. Cloud Hospital

  • Objectives1. Discuss safe medication administration practices in the perioperative setting.2. Review strategies to improve patient safety with regard to high risk or more error prone medication practices.

  • CDC guidelines for safe injection practices1. Use of single dose vials, when available, over MDVa. Use of single dose vials preferableb. Only vials labeled for multiple dose can can be used more than oncec. Beyond use dating (BUD) on multiple dose vials only 28 days unless otherwise specified

  • 2. Adherence to aseptic technique a. Cleaning septum with 70% alcoholb. Proper hand washing techniques3. Use of 1 needle/1 syringe per patient

  • In recent news, there were cases of insulin pens being used on multiple patients. Where the needle connects to the pen, there is a hub. It was found that regurgitation could occur, possibly causing blood/tissue to go into the hub.

  • Incremental/range dosing1. Frequency needs to be based on pharmacokinetics of the medication2. The range should not exceed twice that of the lowest dose3. Initiate at lowest dose of the range4. Monitor patient for clinical response and vital signs

  • Labeling requirements1. Must occur anytime a medication is removed from the original container to another2. Must occur prior to the transfer from original container 3. Original container must be kept as a reference4. Label must list drug name, strength, quantity, diluent and volume

  • Pediatric dosing for pain weight based1. Ibuprofen and Acetaminophen are first linea. Ibuprofen 4-10mg/kg/dose q6-8h prn (max of 40mg/kg/day)b. Acetaminophen:
  • 2. Morphine is second linea. Oral - 0.2-0.5mg/kg/dose q4-6h prnb. IV 0.1-0.2mg/kg/dose q2-4h prn1-6 yo: max of 4mg/dose7-12 yo: max of 8mg/dose

  • 3. Acetaminophen and Codeine- for many years considered the go-to medication for pain in children- no longer recommended because of rapid metabolizers4. Tramadol- use in the Pediatric population (under the age of 16) has not been established

  • Pediatric dosing of antiemetics- Zofran (ondansetron): used primarily for post-operative nausea in children- available in liquid, sublingual tablet and IV- dosing recommendations: 1 month-12yo, 40kg: 4mg IV

  • 6 AORN Medication Safety Concepts1. Storage intermingling same medications but different sizes/strengths in same compartment2. Preparation making the medication as close to the time of use as possible3. Labeling4. Verification do not rely on the cap color or vial shape

  • 5. Disposal ensure that proper disposal containers are available6. Sharps Safety utilize needleless systems

  • High Risk Medications1. Opioid infusions (PCA, epidurals)a. No basal infusion rates for opioid nave patientsb. Opioid nave patients use bolus dosing only2. IV push opioidsa. Initiate at the lowest dose (if range order)

  • 3. Sedation agentsa. Midazolam FDA indicated for sedation not an anxiolyticb. Lorazepam used in sedation and anxiety - Has a half life of 12-14hrs4. Promethazine because of possible tissuenecrosis, we have limited it to IV piggybackthrough a central line

  • NCPS Patient Safety Intervention Hierarchy

    1. Weaker actions (all reliant upon memory and vigilance) a. Double checks b. Warnings and labels c. New procedure/memos/policy d. Training/education e. Additional study/analysis

  • Intermediate actionsa. Redundancyb. Increase in staffing/decreasing workloadc. Software changesd. Checklistse. Read back

  • 3. Stronger actions (focused on system change and not relying on memory).a. Physical changes to environmentb. Forcing functionsc. Simplifying the processd. Must have involvement of leadership

  • Medication Safety Strategies1. Order Setsa. Opioid nave vs. opioid tolerantb. Reviewing ranges and frequencies for appropriateness c. Order sets specific to pediatrics2. Utilizing bar code scanning 5 rights3. Independent double checks 4. Limit vial strength/size

  • 5. Utilizing automatic medication dispensing cabinets6. Document dose prior to administration of medication7. Utilizing smart pumps8. Tracing back the lines9. Patient monitoring pulse oximetry, respiratory rate, capnography10.Utilizing your pharmacist

  • References:Barbara Milani, Nicola Magrini, Andy Gray, Phil Wiffenand Willem Scholten. WHO Calls for Targeted Research on thePharmacological Treatment of Persisting Pain in children with Medical Illnesses. Evid.-Based Child Health; 6: 1017- 1020 (2011). for Medicare and Medicaid Services (2014, March 14). Memorandum: Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids. [On-Line]. Available:

  • The Joint Commission E-dition release 6.0. (2014, January 1). Medication Management Standards (MM). [On-Line]. Available: of periOperative Registered Nurses (2013, May 1). 6 Key Medication Safety Concepts. [On-Line]. Available: for Safe Medication Practices. (2014). ISMPs List of High-Alert Medications. Retrieved September 1, 2014, from

    **Guidelines based off of 4 lge outbreaks of hep C and B. B. no preservatives in single dose vials*Just released in Aug. 2014 SEA #52 preventing infections from misuse of vials*We found that we were leaving pens in medication boxes, after patient was discharged*Monitoring especially in opioids: respiratory rate, oximetry and CO2****Some populations Somali - CYP2D6 ultra rapid metabolizers codeine changed to morphine at toxic levels**How many of you have had an event and do education and policy changes?

    *1. Storage a lot due to shortages, 2. No syringes drawn up and on anesthesia carts**5. We have a list with our black boxes Also speak to wasting in automated drug cabinets*1. Recommendations come from MHA*1. Has amnestic properties. Sometimes used in conjunction with an opioid to for anesthesia induction****2. The scanning system is only smart enough to tell you it is the correct drug, insulin pens. 3. IDC can be a time consuming process and still relies on doing the process correctly*9. If you are not using capnography, you may want to start the conversationAny other ideas? What are you doing in your facility?***