Transcript Slide 1

Medication Safety Practices in Perianesthesia
Care
Jennifer Watson, PharmD
Medication Safety Pharmacist
Centracare – St. Cloud Hospital
Objectives
1. 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 practices
1. Use of single dose vials, when available,
over MDV
a. Use of single dose vials preferable
b. Only vials labeled for multiple dose can
can be used more than once
c. 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 techniques
3. 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 dosing
1. Frequency needs to be based on
pharmacokinetics of the medication
2. The range should not exceed twice that of
the lowest dose
3. Initiate at lowest dose of the range
4. Monitor patient for clinical response and
vital signs
Labeling requirements
1. Must occur anytime a medication is
removed from the original container to
another
2. Must occur prior to the transfer from
original container
3. Original container must be kept as a
reference
4. Label must list drug name, strength,
quantity, diluent and volume
Pediatric dosing for pain – weight based
1. 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 of
60mg/kg/day)
2-12 yo: 12.5-15mg/kg q6h prn (not to
exceed 3750mg/day)
2. Morphine is second line
a. Oral - 0.2-0.5mg/kg/dose q4-6h prn
b. IV – 0.1-0.2mg/kg/dose q2-4h prn
1-6 yo: max of 4mg/dose
7-12 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 Concepts
1. Storage – intermingling same medications
but different sizes/strengths in same
compartment
2. Preparation – making the medication as
close to the time of use as possible
3. Labeling
4. Verification – do not rely on the cap color
or vial shape
5. Disposal – ensure that proper disposal
containers are available
6. Sharps Safety – utilize needleless systems
High Risk Medications
1. Opioid infusions (PCA, epidurals)
a. No basal infusion rates for opioid naïve
patients
b. Opioid naïve patients use bolus dosing
only
2. IV push opioids
a. Initiate at the lowest dose (if range
order)
3. Sedation agents
a. Midazolam – FDA indicated for sedation
not an anxiolytic
b. Lorazepam – used in sedation and
anxiety
- Has a half life of 12-14hrs
4. Promethazine – because of possible tissue
necrosis, we have limited it to IV piggyback
through 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 actions
a. Redundancy
b. Increase in staffing/decreasing workload
c. Software changes
d. Checklists
e. Read back
3. Stronger actions (focused on system change
and not relying on memory).
a. Physical changes to environment
b. Forcing functions
c. Simplifying the process
d. Must have involvement of leadership
Medication Safety Strategies
1. Order Sets
a. Opioid naïve vs. opioid tolerant
b. Reviewing ranges and frequencies for
appropriateness
c. Order sets specific to pediatrics
2. Utilizing bar code scanning – 5 rights
3. Independent double checks
4. Limit vial strength/size
5. Utilizing automatic medication dispensing
cabinets
6. Document dose prior to administration of
medication
7. Utilizing smart pumps
8. Tracing back the lines
9. Patient monitoring – pulse oximetry,
respiratory rate, capnography
10.Utilizing your pharmacist
References:
Barbara Milani, Nicola Magrini, Andy Gray, Phil Wiffen
and Willem Scholten. WHO Calls for Targeted Research on the
Pharmacological 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. [OnLine]. Available:
http://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/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