Medication Safety Alert! April 6, 2017
In this week's issue:
- Two Unsafe Practices: Administration of a Product with a Precipitate and Reuse of a Saline Flush Syringe
- Don't dilute PROVAYBLUE in normal saline
- WHO launches global effort to reduce medication errors
- Are divided doses behind some methotrexate overdoses?
- Dangerous abbreviation - AZT
- Quarterly Action Agenda (January - March 2017)
Problem: Two events recently brought to our attention have again thrust unsafe injection and infusion practices into the limelight. One involves the dispensing and intravenous (IV) administration of a pharmacy-prepared product despite a visible precipitate, and the other involves the reuse of prefilled saline flush syringes for multiple patients, leading to the transmission of bloodborne diseases. We have not previously published the scattered reports we have received related to these unsafe practices, initially believing they were isolated cases. However, these recent events brought to our...