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A hospital float nurse saw an order for influenza vaccine on her patient's medication administration record. She remembered seeing a recent memo stating that the vaccine would be stored in the automated dispensing cabinet (ADC) so that patients wouldn't miss receiving the vaccine if it was prescribed to be given at discharge. But she couldn't find the vaccine in the ADC. She didn't realize that the pharmacy staff had removed the vaccines in response to a recall because of incorrect needle attachment to the unit-dose syringes.
The nurse found another drug that appeared to be flu vaccine and used the override feature on the ADC to obtain the medication. Luckily, before she administered the drug, she asked a pharmacist if she should put the rest of the flu vaccine back in the ADC after she drew up the dose needed for her patient. The pharmacist, knowing that no vials of the vaccine were in patient-care units, discovered that the nurse had drawn up 0.5 mL of flumazenil, a benzodiazepine receptor antagonist indicated for the complete or partial reversal of benzodiazepine-induced sedation.
The safest practice is to have the pharmacy dispense vaccines when they're prescribed. Other steps to prevent errors include:
* warning users if the vaccine is kept in an ADC with other drug names that start with "flu," because confusion could arise when drug names appear sequentially on selection screens.
* remembering that overriding an ADC can signal an error. Instead of overriding the system, investigate why the drug isn't in the ADC.
* remembering that vaccines need to be refrigerated, so removing a drug thought to be a vaccine from a nonrefrigerated portion of the ADC is another red flag that suggests an error.
If your facility uses volume control sets (such as the Buretrol or Soluset volume control sets) to deliver I.V. medications, check how they're being used in patient-care units, including the ED. Because the drug is injected into a chamber, no drug identification information appears on the chamber (as it would on a minibag).
This lack of identifying information can be dangerous, particularly in an emergency. Another concern is the potential for chemical inactivation or precipitation in the volume control set or I.V. tubing when multiple medications are administered using the same set.
A volume control set is an inline receptacle (usually with a maximum capacity of 150 mL) between the patient's I.V. catheter and the I.V. solution. The theory behind the use of the volume control set is that it helps protect the patient because it can be filled only to a certain level; if the I.V. pump malfunctions, then only that volume will flow into the patient. These devices are sometimes used to protect against an inadvertent free flow of I.V. fluids that can lead to an overdose.
If your facility uses volume control sets, make sure you label the chamber appropriately, use separate chambers for each drug, and maintain sterile technique.
Generic methylergonovine maleate, a semisynthetic ergot alkaloid used to prevent and control postpartum hemorrhage, is packaged in a vial and available from PharmaForce, Inc. The generic drug is being used in some hospitals instead of brand-name Methergine, which is packaged in ampules and overwrapped in amber plastic. The ampules are difficult to open, and the packaging has led to confusion with Brethine (terbutaline) ampules.
Although the vials of methylergonovine maleate are an improvement, the plastic caps on the 1-mL vials are the same shade of green as the well-known oxytocin vials available from JHP Pharmaceutical, as shown above. (Oxytocin promotes uterine contractions by increasing intracellular calcium.) Depending on how the vials are stored, their similar cap colors and vial size could be confusing. Both drugs are used in obstetric units, and a mix-up of the two would be disastrous.
The Institute for Safe Medication Practices has contacted PharmaForce, and the company is in the process of changing the cap color. Until then, hospitals may want to hold off on storing the generic product in obstetric units.
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