Medication Safety Alert! October 4, 2018
In this month's issue:
- Mix-ups Between Epidural Analgesia and IV Antibiotics in Labor and Delivery Units Continue to Cause Harm
- FDA draft guidance clarifies requirements for barcodes and expiration dates
- Label format used by some outsourcers
- FDA cautions on misuse of pen needles
- Acute Care Action Agenda (July-September 2018)
Problem: Within weeks of each other, two hospitals have reported mix-ups between epidural analgesia and intravenous (IV) antibiotics in labor and delivery (L&D) units. These mix-ups mimic previously published events and have similar contributing factors including look-alike infusion bags, overlooked warning labels, and a point-of-care barcode medication administration (BCMA) system that was not fully engaged. However, unlike the prior events, drug shortages also played a role in the most recent errors.
Epidural fentaNYL with bupivacaine administered IV. An obstetrician...