Pharmacy & Therapeutics - May 2008 - (Page 261) MEDICATION ERRORS bers that are clearly visible on the packages, the kit number should be included within the applicable order sets to ensure that the kit’s distribution and use match the desired function. 2. Only pumps with a reservoir port should be used. With children or in other appropriate situations, implant pumps with a single port for the drug reservoir should be used to reduce the risk of inadvertent direct administration of concentrated agents. 3. The kits should be kept in separate locations. The manufacturer’s labeling is not easy to identify or differentiate from others when the kits sit on a shelf. If pumps with both ports are used, refill and catheter access kits should be stored separately. a. Refill kits could be kept in a secured area (e.g., in the pharmacy), and catheter access kits not containing medications could be kept in another location (e.g., in the physician’s office or radiology department). b. Refill kits containing different doses of medications should be stored in a separate area. 4. The kit and port should be verified to ensure that they are correct. a. All personnel should follow the manufacturer’s written procedures. b. The clinician who performs the procedure should verify the kit number with the number on the standard order form. c. The clinician should open the kit so that warning messages are less likely to be overlooked. d. The template in the kit, not just palpation, should be used to locate the port. e. Time should be allowed for two clinicians (or a clinician and a patient) to independently double-check the kit, template, and medication (if the pump is being refilled). f. During the refill, the clinician should try to validate the puncture into the reservoir by aspirating the estimated volume of medication remaining before refilling the pump. g. Small amounts of the medication (3 to 5 mL) should be injected and aspirated into the reservoir before the pump is refilled with the entire dose. h. The full volume injected should be readily aspirated and colorless. i. If the aspirate appears not to be a medication, a sample can be tested with a reagent strip to determine the presence of glucose and protein. Such findings suggest that cerebral spinal fluid or other body fluids, respectively, have been aspirated in error. 5. Clinicians should be trained and experienced in the procedures. a. If SynchroMed infusion pumps are used, special privileging and periodic competency validation are essential for all physicians, physician assistants, nurse practitioners, nurses, and pharmacists who are involved in prescribing, implanting, programming, dispensing, or refilling the pumps or kits. b. Each staff member should be thoroughly oriented to the pump’s use and should understand the potential for lifethreatening effects if an error occurs. c. If implantable pumps are used infrequently and if this makes it difficult to maintain proficiency among personnel, patients should be referred to other health care providers who handle these pumps more regularly. 6. Patients should receive current information. Because pump refills occasionally take place in a location where the patient’s medical records are not available, patients should be given an updated card or sheet with the manufacturer and model number of the device; the pump’s reservoir capacity; the date of the last refill; and the medication’s name, concentration, and programmed dose. Clinicians should refer to this card during each encounter with the patient. 7. All clinicians should be prepared for errors. Written guidelines should be established for early recognition of an error (leg pain, seizures). If an error occurs, prompt treatment, such as active irrigation and drainage of the CSF, respiratory support, treatment of myoclonic seizure activity, and small incremental doses of reversal agents should be instituted. tion Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the ISMP (www.ismp. org) or the USP (www.usp.org) Web site or communicated directly to ISMP by calling 1-800-FAILSAFE or via e-mail at ismpinfo@ismp.org. I LETTERS TO THE EDITOR On Diabetes Care in America And the Power of Prevention Dear Dr. Nash, I am preparing to complete my fourth year of medical school at the University of South Florida College of Medicine. As a strong proponent for lifestyle medicine, I greatly enjoyed your recent editorial that appeared in the March 2008 issue of P&T, entitled “Changing Diabetes Care: An Op portunity for the Feds.” Your reflections were right on target and very timely. I was also struck by how closely a recent presentation I gave was mirrored in your words and figures. The presentation, called “The Power of Prevention,” was made to a group of students and faculty at USF. I recently posted it online for public viewing at www.authorstream.com. The presentation carefully outlines the growth of lifestyle diseases (type2 diabetes and the metabolic syndrome in particular) over the last 30 years. It then presents the medical literature that supports lifestyle intervention and addresses common misconceptions and challenges ahead. The data are disturbing when you look at the personal and financial costs to our nation, but they are optimistic when you see how powerful lifestyle inter ventions can be. I hope you will pass on the link, and I know you will never stop being a passionate voice for rational health care. Many thanks for your continued leadership in this area. I am hopeful that the future will bring change, and I am excited by the opportunity to be part of it. Sincerely, Stephan Esser continued on page 298 Vol. 33 No. 5 • May 2008 • REFERENCES 1. Sauter K, Kaufman HH, Bloomfield SM, et al. Treatment of high-dose intrathecal morphine overdose. J Neurology 1994;81: 143–146. 2. Wu CL, Patt RB. Accidental overdose of systemic morphine during intended refill of intrathecal infusion device. Anesth Analg 1992;75:130–132. The reports described in this column were received through the USP–ISMP Medica- P&T® 261 http://www.ismp.org http://www.usp.org http://www.ismp.org http://www.authorstream.com
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