Bold Voices - January 2011 - (Page 15)

AT THE BEDSIDE DTaP, Tdap: What’s in a Name? Hundreds of accidental mix-ups between products used for immunizing adult versus pediatric patients against diphtheria, tetanus and pertussis might affect thousands of patients, alerts the Institute for Safe Medication Practices (ISMP), Horsham, Pa. “DTaP-Tdap Mix-ups Now Affecting Hundreds of Patients” indicates, “Part of the problem is that the official names of these products,” Adacel [Tdap] and Daptacel [DTaP], “are very similar although stated in different order on the labels.” ISMP, which first reported the problem in 2006, adds that these mistakes largely occur because of similar names and the abbreviations used for vaccines that range from diphtheria to tetanus. The uppercase letters in DTaP — the children’s dose — correspond with a higher antigen quantity in the diphtheria and pertussis components, the alert states. It is often mistaken for the lowercase Tdap, which may result in an adult not needing revaccination but the higher antigen dose may cause “a sore arm at the vaccination site.” Conversely, “an infant/child who got Tdap would Similar names make it easy to confuse have received a lesser amount of antigen and may not respond adequately,” it adds. The problem occurs most vaccinations for kids and adults. often in clinical settings where the vaccines are mixed up and stored in the wrong area of a refrigerated ADC cabinet, states the ISMP, which recommends storing adult and pediatric doses in different areas. According to the alert: “One hospital reported a significant reduction in mix-ups by employing a ‘time out’ procedure before dispensing and administering these vaccines. Each ‘time out’ is conducted by at least two clinicians and is guided by a laminated card with pictures of the two different products for reference.” The ISMP also recommends prescribing medications by the brand name versus the abbreviated name and making parents and caregivers aware of MIND-BODY the vaccine names “by writing them down beforehand or handing the patient a printed sheet that also details the purpose of each vaccine.” Ask the parents and caregivers to help verify the vaccine Make Good on Your Resolutions before it’s administered, the alert adds. HAPPY NEW YOU Buy them online w w w. a a c n . o r g / n e w y o u AACN BOLD VOICES JANUARY 2011 15

Table of Contents for the Digital Edition of Bold Voices - January 2011

Front/Digital Edition Viewing Guide
Another Angle
AACN Boards and Contact Information
New HHS-CCSC Awards Recognize HAI Reductions
Zero Tolerance for Preventable Incidents Involves Non-Surgical Specialties
Bold Voice: Chatting with MaryAnn Stump
Facebook Asthma?
EOL Care Rises for Heart Failure Patients on Medicare
More Patient, Family Contact Needed in EOL Care
Chronic Lung Disease of Prematurity Increases Respiratory Risk in Day Care
Childhood Obesity Linked to Viral Infections
Pharmaceutical Safety at Home
DTaP, Tdap: What's in a Name?
In Our Journals
STOP-BANG Helps Identify Surgical Patients at Risk
Fewer Blood Transfusions Can Improve Patient Safety, Reduce Costs
Certification Capsules
Dues, NTI and Certification Fees Will Not Increase
From the President

Bold Voices - January 2011