VA patient safety advisory on High Alert Medications in the OR
August 2, 2010
Veterans Administration Health System
Patient Safety Advisory AD10-03
Item: Epinephrine, Phenylephrine, and other High Alert Medication Safety in the Operating Room
General Information: Administration errors of epinephrine, phenylephrine or other High Alert Medication (for a list of drugs, see ISMP High Alert Medications) as the result of selecting the incorrect concentration or wrong drug (look-alike/ sound-alike) can result in significant patient harm, including death. Although recurrent incidences within the VA of inadvertent administration of concentrated phenylephrine or epinephrine prompted the need for this patient safety advisory, it should be noted that this patient safety advisory is applicable for all High Alert Medications used in the OR.
Key Recommendations:
- Ensure high-alert medications are stocked in ready-to-use dosage forms when commercially available. Stocking and use of multi-dose vials should be minimized.
- Standardize and minimize the number of medication concentrations stocked.
- Identify high risk medications that require dilution prior to administration (e.g., phenylephrine) and develop a process to assure these are available in the diluted form only. (Some VAMCs have the Pharmacy Dept. prepare these daily.)
- Epinephrine concentrations should be communicated and labeled in mg/mL strength rather than ratio strengths, such as 1:1,000.
- Restocking of automated dispensing cabinets (ADCs) should incorporate bar-code technology or a suitable double-check to ensure stocking of the correct drug and concentration.
- If the VAMC is using an ADC, open vials of medications, not used during procedures, should not be restocked in the ADC by the end-user.
- All medications on and off the sterile field must be labeled. All unlabeled solutions or medications are to be discarded.
PharMEDium OR Anesthesia syringes support each of the key recommendations detailed in the Patient Safety Advisory AD10-03.
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