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nurse mar06-v5.qxd - Institute For Safe Medication Practices
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1. i m Fip E ISMP Medication Safety Alert Nurse Advise ERR Educating the healthcare community about safe medication practices Patient s watchful eye leads to pump tampering A hospitalized patient with chronic pain was able to increase the rate of his HYDROmorphone DILAUDID infusion and administer bolus doses to himself The patient had been receiving HYDROmorphone via a CADD Prizm VIP pump from Smiths Medical at home before he was admitted to the hospital late one evening The admitting physician prescribed the same dose of HYDROmorphone as the patient had been receiving at home and allowed the patient to use his pump from home while in the hospital given himself frequent boluses not prescribed The patient s home CADD pump was replaced with a hospital CADD pump different model and secured with a lock to prevent further tampering Obviously the patient knew how to manipulate the pump He had obtained and used the lock level code to alter the pump settings and the clinician code to give himself bolus doses But how did he gain this knowledge At the request of FDA and The hospital based pain The others to provide readily service team had been patient accessible information following the care of the patient at home But the team was not notified of his admission until the following morning when a resident called them to ques tion why the patient s HYDROmorphone was infusing at a
2. different rate than prescribed The team member told the resident that they had not changed the dose and would be unable to see the patient until later in the day because of a busy clinic schedule The resident did not investigate the change in the infusion rate any further Eighteen hours elapsed before the pain service physician was able to visit the patient Nursing documenta tion regarding how much medication should have infused differed signifi cantly from the pump s electronic patient history log When comparing the two the physician quickly discov ered that the patient had somehow manipulated the infusion rate and 2006 learned the codes by observ ing practitioners while program ming the pump the pump s user manual is available on the manu facturer s website This provides patients with knowledge about how to program the pump How ever the codes are not in the web publications they appear only in the hardcopy of the user manual that the facility receives Thus the patient likely obtained the lock level and clinician codes for the pump he used at home by observing practition ers programming the pump in the hospital A much less remote possi bility is that the codes which are the same for this pump throughout the US when shipped from the manufac turer had been communicated via the Internet or email by others While there may be no foolproof way to prevent patient tampering with pumps see check
3. hed errors were received through the USP ISMP Medication Errors Reporting Program Editors Judy Smetzer RN BSN Nancy Tuohy RN MSN Michael R Cohen RPh MS ScD Russell Jenkins MD ISMP 1800 Byberry Road Suite 810 Huntingdon Valley PA 19006 Tel 215 947 7797 Fax 215 914 1492 EMAIL nursing ismp org Report medication errors to ISMP at 800 FAIL SAF E ISMP seeks an RN Medication Safety Specialist for publications Details at www ismp org jobline
4. mediately Patients and visitors have used pens paper clips or other objects to push the syringe plunger syringes with long needles to aspirate the medication or moderate pressure to open the locked compartment v Change codes Some pumps offer biomedical engineering staff the capa bility of changing the lock level and clinician codes Consider requesting a temporary code change for patients at risk for tampering with the pumps as long as the new codes can be securely communicated to all practitioners who need the information S Notify the pain service If your facility offers a pain service notify the team immediately upon admission of a patient with chronic pain especially if the patient has been receiving opioids in the home setting Mos ursing PDQ for Medication Safe epared by ISMP This pocket sized nce has quick facts and error reduction strategies for high alert medica maim tions look alike drugs itera ome high risk procedures and p DQ erro wy tio offers information and tips on assessing risk error reduction error reporting and more For info and to order please visit http estore ismp org ISMP Medication Safety Alert Nurse Advise ERR ISSN 1550 6304 2006 Institute for Safe Medication Practices ISMP Permission is granted to subscribers to reproduce material for internal newsletters or communications Other reproduction is prohibited without written permission Unless noted publis
5. nder that such an event is possible In fact there are a few additional conditions that heighten the risk of connecting the V A C tubing to an IV line Most V A C topical solutions are prepared in IV bags so both the bags and tubing look like those used to deliver IV solutions The V A C provides a detachable IV pole as described in gt Special Announcement product literature upon which to hang the solution Finally the V A C is indicated for recalcitrant wounds so it s used infrequently Thus staff may be unfamiliar with the device and unaware of the risk of miscon nections Furthermore there will be no protection from gravity free flow if the tubing is erroneously attached to an IV site and later removed from the V A C Photos of the V A C Instill System are available online at www kcil com 866 asp The reporting nurse has asked the manufacturer KCI to develop spe cific tubing that connects only to their equipment Meanwhile mis connections are less likely if you label all lines physically trace all lines from the source solution to the port of insertion and require an inde pendent double check before initial use of the device or when replacing bags of solutions Additionally ask pharmacy to apply an easily visible For irrigation use only label and a brightly colored overwrap before dis pensing Also consider asking phar macy to prepare topical solutions in a container dissimilar to
6. or appears different than expected v Patient education Be sure patients understand how to report increasing or unrelieved pain Some patients who experience difficulties with pain management are driven to extremes for relief Provide assurance that you will contact their physician about unrelieved pain who will subse quently assess and manage the patient s pain more effectively v Staff education When educating Staff and other caregivers to use pumps stress ways to minimize the risk of patients and visitors learning the programming codes continued on page 2 Nurse Advise ERR Page 2 March 2006 Volume 4 Issue 3 Another risk of IV misconnections and free flow The V A C INSTILL SYSTEM by KCI is a wound healing system that facilitates automated delivery of top ical solutions e g Dakin s solution silver nitrate solution SULFAMY LON mafenide acetate to wound sites While very different from an infusion pump the device is pro grammed to deliver irrigation fluid at a desired rate but it lacks protection from gravity free flow if the tubing is removed Unfortunately the V A C is designed to accommodate IV tub ing to deliver the topical solution Thus a nurse could inadvertently attach the IV tubing intended for the V A C to an IV port Previously reported misconnections of seemingly dissimilar tubing e g blood pressure oxygen and air sup ply tubing to IV ports should serve as a remi
7. tout for several things that healthcare providers can do to reduce the risk of tampering or to detect it quickly if it occurs We are pleased to announce that McKesson will continue to provide ISMP with an edu cational grant to sponsor free distribution of Nurse Acvise ERR for the remaining 6 months of 2006 Join us in thanking them by emailing for customers mckesson com Supported by an educational grant from McKesson March 2006 Volume 4 Issue 3 To reduce the risk of patient tampering with pumps that deliver opioids or to detect such tampering quickly v Use hospital pumps To enhance security use only hospital approved pumps to administer opioids to hospi talized patients Do not allow patients to use their pumps from home v Shielding and scrolling When programming a pump always block the patient s and visitor s view and use the scroll up or down keys if avail able to prevent patients from counting how many times the keys are pressed v Checks and balances Require the use of carefully designed flow Sheets during opioid infusions to track Cumulative doses over time 4 nour increments for inpatients while refer encing the pump s patient history log for comparison to the prescribed dose Y Investigate Consider the possibility of patient tampering or an error if the amount dose and volume adminis tered does not match the prescribed dose or if the patient s sedation level respiratory status or behavi
8. typical IV solutions such as a 500 mL bottle ISMP Teleconferences Please join us for a two part teleconference series covering Just Culture Part Just Culture An Emerging Safety Centered Accountability Model will be held on March 30 2006 Part Il Journey Toward a Just Culture A Statewide Initiative will be held on April 19 2006 Both programs will be held from 1 30 to 3 00 p m ET In Part David Marx JD will describe the basic tenets of a Just Culture a groundbreaking way to promote an open and fair healthcare environment especially as it relates to error investi gation This is a repeat of our October 2005 teleconference Speakers for Part II will chronicle the statewide effort among healthcare providers and state licensing boards to adopt a Just Culture throughout the healthcare industry in Minnesota Shirley Brekken from the Minnesota State Board of Nursing Tania Daniels from the Minnesota Hospital Association and Alison Page from Fairview Health Services will be the featured speakers each bringing a unique point of view to the experience For details and to register visit www ismp org teleconferences tc asp continued trom page 1 check tout V v y Check security features Check all pumps used for opioid infusions and new pumps considered for purchase to ensure that the locking mechanism for the compartment that holds the medication is functional and reliable If it is not request a replace ment pump im
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