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Near-fatal pediatric accident should force reassessment of a common cost-cutting measure

From the August 25, 1999 issue

PROBLEM: In previous newsletter issues, we've discussed errors where syringes of medication were mistaken for saline flush solutions for IV catheters. Such errors often result from look-alike labeling and packaging of multiple-dose vials or unlabeled/mislabeled syringes. That's exactly what happened recently in a pediatric emergency department (ED) where vecuronium was administered to an alert three-year-old child who was not ventilator supported. In this case, commercially-prepared prefilled saline syringes were not available in the ED, so nurses drew up supplies of saline flush syringes from multiple-dose vials, labeling them by hand. Prior to the child's admission, vecuronium syringes had been prepared for another patient. An unused syringe of vecuronium, hand-labeled similarly to the saline syringes, somehow found its way into the saline supplies. As a result, the syringe containing vecuronium was mistakenly used to flush the child's IV line. The child became frightened and flaccid. All respiratory efforts ceased, and he was quickly intubated and ventilated. Personnel identified the error upon closer inspection of the syringe. The child was treated supportively and sustained no serious harm. The child's father, who was present at the time of the incident, reported it to the local press and the event received extensive local media attention last week.

SAFE PRACTICE RECOMMENDATION: In many facilities where serious errors have occurred after replacing commercially available prefilled syringes of saline and heparin with multiple dose vials, practitioners and hospital leadership are reassessing the value of this cost-saving measure. The above case is one of many in which an error could have been prevented by using commercially available prefilled syringes. Their use in all patient care units, when possible, is an important safety measure that combines unit-dose packaging and proper labeling of all syringes. In fact, any cost savings felt to be achievable through the use of multiple dose vials can be quickly consumed, as errors and cross contamination between patients are more likely when commercially available prefilled syringes are not available. Likewise, the case above is one of many in which a neuromuscular blocking agent was accidentally administered to a patient who was not intubated and properly sedated. Ideally, these agents should not be stored in patient care units, and pharmacy should dispense each dose outside the O.R. with a bright "anesthesia red" auxiliary label that states, "WARNING, PARALYZING AGENT" (available as a custom item from label suppliers such as United Ad Label Co. 800 992 5755). If these agents must remain in patient care areas (such as the emergency department or critical care units), place the vials in plastic bags, apply the red auxiliary warning label on both sides of the bag, and require the same labeling for any syringe of neuromuscular blocker that leaves the preparer's hands. Also, sequester these drugs in a locked or secured box in the refrigerator or elsewhere as appropriate. Immediately discard syringes of unused or partially used doses. It's dangerous to allow anyone, especially untrained staff who may not recognize the hazard, to replace unused neuromuscular blocking agent doses into stock. Restricting use of neuromuscular blocking agents affords some measure of safety. However, it will not prevent practitioners from mistaking an unsecured vial for another look-alike vial, nor will it prevent drug name confusion. Require two nurses to independently check each dose before administration. Finally, establish a policy to automatically discontinue all neuromuscular blocking agents once patients are extubated. ISMP has been actively participating on a USP Advisory Panel in an effort to reduce medication errors with this class of drugs. Recommendations will include safe labeling and dispensing standards for manufacturers and practitioners.

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