Do you know what drugs are present on your nursing units?
In a hospital that performs organ transplants, a 20,000 units/mL heparin vial was found in the hospital’s operating room (OR) even though the hospital never purchased or distributed such a product, after it was felt to be an unsafe and an unnecessary concentration to stock. After much investigation, it was found that an organ harvesting team had brought it into the medical center, intending to use it during the case. However, it went unused and was left in the OR. In another organization, a hospital-contracted renal transplant service left sodium chloride 23.4% on several nursing units where they often brought in portable hemodialysis machines. Sodium chloride 23.4% was sometimes used to reduce cramping during hemodialysis. We wrote about a similar event, first in 2005 and then in 2010, in which a transplant team left behind a bag of ViaSpan cold storage solution, which turned up in the pharmacy return bin because it looked so much like an IV solution bag. Inadvertent IV administration of the solution would almost certainly cause cardiac arrest due to the high potassium content (about 125 mEq/L). Serious medication errors often involve an unfamiliar product, so this is not a minor issue. Situations like this are one reason that pharmacy staff must take monthly nursing unit reviews seriously. When outside groups contract to provide services, hospital leadership must notify the pharmacy director to ensure that the medications and dosage forms that might be used are reviewed and agreed upon by the pharmacy. At that time, alternative products may be discussed and/or arrangements made to securely store products normally unavailable at the hospital.