medication safety practices in perianesthesia care jennifer watson, pharmd medication safety...

Medication Safety Practices in Perianesthesia Care

Jennifer Watson, PharmDMedication Safety Pharmacist

Centracare – 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 MDV

a. 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% alcohol

b. 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 line

a. Ibuprofen 4-10mg/kg/dose q6-8h prn (max of 40mg/kg/day)b. Acetaminophen:<2 yo: 7.5-15mg/kg/dose q6h prn (max of60mg/kg/day)2-12 yo: 12.5-15mg/kg q6h prn (not toexceed 3750mg/day)

2. Morphine is second linea. Oral - 0.2-0.5mg/kg/dose q4-6h prnb. IV – 0.1-0.2mg/kg/dose q2-4h prn

1-6 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 metabolizers

4. 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: 0.1mg/kg/dose

IV 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 naïve patients

b. Opioid naïve patients use bolus dosing only

2. 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 12-14hrs

4. 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/memo’s/policy d. Training/education e. Additional study/analysis

2. 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 Sets

a. Opioid naïve 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 Wiffen

and 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). www.evidence-basedchildheath.com.

Centers 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: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/index.html

The Joint Commission E-dition release 6.0. (2014, January 1). Medication Management Standards (MM). [On-Line]. Available: http://e-dition.jcrinc.com/Frame.aspx

Association of periOperative Registered Nurses (2013, May 1). 6 Key Medication Safety Concepts. [On-Line]. Available: http://aorn.org/News.aspx?id=24794

Institute for Safe Medication Practices. (2014). ISMP’s List of High-Alert Medications. Retrieved September 1, 2014, from http://www.ismp.org/Tools/highalertmedications.pdf