1. Patient Safety WHO collaborative High 5s topics Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical errors Accurate medicines reconciliation Prevention of high concentration drug errors Promotion of effective hand hygiene practices http://www.who.int/patientsafety/solutions/high5s/en/index.html

2. SOP - Management of Concentrated Injectables “worldwide evidence that concentrated injectable medicines have been involved in medication incidents resulting in death or serious harm” WHO 2007 http://www.who.int/patientsafety/solutions/high5s/Managing-concentrated-injectables.pdf

3. Basic principles Simplify and rationalise protocols and range of products Minimise calculations and preparation in clinical setting Procure ready-to-administer or ready-to use products that require no further dilution before use

4. Identified Conc Injectables Potassium Chloride and Phosphate soln Heparin > 1000units/ml Concentrated morphine & opiate injections Hypertonic Saline Magnesium Sulphate >50% Any other injections in high concentrations that cannot be administered safely to patients. Injectables as highlighted by reported incidents, e.g. ciclosporin, tranexamic acid, amiodarone.

5. Identify all types & location of CIs Standardize and limit the number of concentrations Procure suitable premix bags Is there still a valid clinical need for CIs ? Yes Determine minimum amount CIs for safe care. Identify secure and segregated storage of CIs Ensure Smart pump profile & Policies/ Procedures current Train authorised staff to access and use CIs Evaluate CIs usage and clinical need annually Procure additional premix bags and set stock levels Ensure Smart pump profile & Policies/ Procedures current Monitor usage of premix bags annually No Remove CIs from these clinical areas Procure additional premix bags and set stock levels Ensure Smart pump profile & Policies/ Procedures current Monitor usage of Premix bags annually Process Flow used for Managing Concentrated Injectable Medicines

6. What is the problem? KCl in Conc ampoule form can be fatal if not handled properly! Usage of KCl ampoules = ??? p.a. Essential areas (ICU CCU ED) = ??p.a. X reported incidents at XDHB in last 6 months and 1 nationally, all potentially serious. Action taken already: KCl concentrate ampoules stored securely on X wards in XX DHBNZ Audit 2009 X x KCl premixes in use = XX p.a Protocols rationalised to X documents (ICU & Adult)

7. Date Description of IncidentFollow up 27-Dec-08Patiert potassium level was 2.5. Dr charted 100mls 0.9%saline bag and 14mmol of potassium cholride at 33mls an hour. Checked the infusion with RN. I went to give the infusion and as soon as it started patient 7 years old began to yell out in pain. I stopped the infusion immediately and when I checked the pump it read volume infused zero mls. The IV line was patent and there was no redness at The site. I discussed this with Dr and Mum requested it be diluted further. The doctor recharted the transfusion to 200mls 0.9% Saline bag with 14mmol of KCl. I again checked this with RN. The infusion was taken to the bedside and commenced. Again child began to yell out in pain and I stopped the infusion immediately and when I checked the pump it read volume infused zero mls. The IV line was checked and it was patent and there was no redness at the site. I then discussed with Dr, who re charted 0.45%NaCl + 2.5%Dex 500ml bag with 20mmol KCl. Mum requested that the infusion start at 30mls an hour, patient tolerated this reporting no pain and there was no redness at site, after approximately one minute Mum requested the infusion rate increase to 60mls an hour, this was also pain free. Mum then asked if the rate increased to 90mls/hour as charted. This was well tolerated and there were no further concerns. 06-Mar-09Pt charted KPO4 20mmol x2 via peripheral line. Nurse identified with H/Surgeon that pt didn't have CVL. Recharted by H/Surgeon as "KPhos (per 500mls) 20mmol x2". Nurse gave 20mmols in 500mls over 1 hr – risk of overload to pt). Identified by another SN and rate slowed to 70mls/hr & Dr advised. Further information from patient’s chart LH 9/3/09 : Was on D5W at 70mls per hour then bloods showed low K+ and low Phosphate. Charted and made up 40mmol/1 lit D5W and given at 500mls/hour (outside of Protocol and standing order guidelines) until noticed and stopped by second nurse. 04/06/09FWD8655 M 63Y, Othapedic Surgery. Pt. arrived in Recovery @1948 after surgery. Supposed to have a GIK running as IDDM Gik from ECCmade incorrectly with 0.18%NACL and 4%Dextrose Instead of 10%Dextrose with 10mmol KCL. No clear documentation as to change and fluid incorrectly charted on fluid balance. No signature for order.no record of when previous infusion had completed. This incorrect fluid commenced at 1715 in ECC No labs after 3/06/09. LH Spoke with C/N to alert to incident. Bag hanging correct on 4.06.09

8. How do we solve it? Add 3 more pre-mix bags over next 12 months and remove ampoules from all but essential clinical areas. 1. 10mmol KCl in 10% Glucose 500ml (GIK): Currently bag made on ward by nursing staff Estimate XDHB use @ 5000 bags p.a. Premix would replace 5000 KCl ampoules and glucose bags Release 1000hrs nurse’s time to care Purchase premix for 1month trial in ward ? Ready to start asap.

9. 2. 40mmol KCl in N/Saline 1000mL: Currently bag made on ward by nursing staff Estimate use @ 1500 bags p.a. Purchase premix at $7.5k saving Release 200hrs nurse’s time to care Replace 6000 KCl ampoules Introduce with education 3. Paediatric bag 500ml: Formula in consultation with consultants and Starship not yet finalised. (awaiting Aust stds)

10. Have we made a difference? By adding 2 more premix bags, 1 x GIK, 1x N/S with KCl 40mmol to stock a total of 4 premixes. XDHB would expect: ↓ KCL amps by X p.a. Conc KCl removed from wards If KCL or K Phosphate to remain as clinically valid then that could be managed as controlled drug with two witnesses Store KCl amps in essential areas only Monitor errors reported Minimise volumes of premix stored by improved stock rotation.

11. From this to this! The Productive Ward