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Involving non-clinical departments in patient safety discussions can reduce the risk of serious errors

From the September 4, 2002 issue

PROBLEM: A patient safety nurse visited the operating room (OR) to speak with staff about one safety matter but she wound up uncovering another. While in an OR utility room, she happened to observe a pale pink disinfectant/deodorant solution packaged in a semi-rigid container with graduated volume markers on one side, similar to the sodium chloride irrigation solution containers purchased by the hospital. The disinfectant also had a plastic loop affixed on the bottom similar to the loop used for hanging irrigation solutions on an IV pole. Close inspection of the bottle (see photograph on our web site) and subsequent investigation revealed that housekeeping personnel routinely obtained bottles of sterile irrigation solutions, added a disinfectant concentrate to the contents, and placed a manufacturer-provided label over the sodium chloride irrigation label.

The nurse's chance observation may have prevented a tragedy. On more than one occasion, ISMP has learned of situations where repackaged non-drug substances were confused with medical or other products. In our April 7, 1999 issue, we mentioned that antibiotic solutions were inadvertently reconstituted with 10% formalin solution (3% formaldehyde and 15% methanol) in two different pharmacies. In both cases, non-pharmacists working in the pharmacy routinely used already empty plastic gallon jugs of distilled water to prepare 10% formalin for nearby surgical centers. Formalin labels were affixed to one side of the container but occasionally the distilled water labels were also left on the containers in error. These were accidentally placed with empty jugs of distilled water where they were later used to reconstitute antibiotic suspensions for a total of 35 children, some of whom required hospitalization. Likewise, people handling the above irrigation containers could forget to properly relabel the irrigation bottles or they might place the label on the opposite side of the container, leaving the original irrigation label exposed. One of our reviewers pointed out that in the book "Set Phasers on Stun" by Steven Casey, one of the safety lesson anecdotes is about a bar that routinely used empty liquor bottles to store caustic cleaners. Until one was eventually mistaken for a peppermint twist and a patron lost their esophagus lining!

SAFE PRACTICE RECOMMENDATION: The Department of Veterans Affairs, National Center for Patient Safety, promotes the idea that patient safety considerations should go well beyond clinicians. Time should be allotted at all department head meetings, not just professional department meetings, to review appropriate patient safety issues discovered within the organization or through external reports. For example, take the time at an upcoming department head meeting to present the disinfectant case above to all department heads, especially those in support areas such as dietary, housekeeping, central supply, laundry, etc. Explain why it is dangerous to repackage nondrug items into empty drug, solution, or irrigation solution containers or to add nondrug items to solutions in these containers. Develop a hospital policy that forbids the practice, especially in the absence of appropriate pharmacy oversight. Even go so far as to poke a hole in empty plastic containers to prevent reuse with another fluid (although people could still empty a full container). Have pharmacy staff routinely assess the risk of accidental administration of nondrug substances during visits to various hospital areas. In our visits to hospitals to analyze their medication system for safety, we've noticed soaps, topical substances, tissue fixatives, detergents, and even poisonous substances in bottles that look like drug containers. Who can say for sure that staff would never confuse one of these with an internal or external therapeutic product? Unfortunately, that's happened all too often.

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