Medication Safety

Drug monitoring in IV tubing using Raman spectroscopy

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chemistryworld: “Recent research, led by Brian Cunningham at the University of Illinois in the US, has produced biomedical tubing that uses surface enhanced Raman spectroscopy (SERS) to monitor the contents and concentrations of drugs within a patient’s IV line.  The plasmonic nanodome array surface enhances the Raman signals.  The tubing could detect 10 pharmaceutical compounds with reproducible signals for a period of up to five days. For four of the drugs, the signal magnitude was dependent upon the drug concentration and combinations of compounds could also be detected, giving a much more detailed picture of a patient’s medication.” – This is great work being done by the University of Illinois. I’ve contemplated something like this in the past.

SERS_IVdrugID

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Accuracy of preparation of i.v. medication syringes for anesthesiology [article]

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Here’s an interesting article from the January issue of AJHP that talks about the accuracy of medication syringes used in surgical procedures. Some of the findings are a bit unnerving: “18% of preparations deviated from the declared dose by ±20%, 8% deviated by ±50%, and 4% deviated by ±100%“. Humans, we’re just not all that … Read more

Combination lock to prevent blood transfusion errors? Why not

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medGadget: “Typenex Medical, a Chicago, Illinois company, has created a solution that pretty much eliminates the possibility for errors. The system utilizes a combination lock on the blood bag that will only open using a code printed on the patient’s armband. If a clinician accidentally attempts to open the bag using another patient’s code, it … Read more

More on the meningitis outbreak caused by contaminated steroid injection

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Things just keep getting worse: death toll rose to 14 and people affected was up to 172 in 11 states as of this afternoon. It’s difficult to find accurate information on the exact cause of the meningitis, but it appears that most of the cases are related to either Aspergillus or Exserohilum. Fungal infections are … Read more

Outsourcing sterile product preparation and the importance of quality assurance

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I’m sure you’ve heard about the recent meningitis outbreak tied to a contaminated batch of preservative-free methylprednisolone acetate. The story has received significant attention as more that 100 people have been sickened and as many as eight have died as a result of receiving an injection of the contaminated steroid (this data is already out of date since I started composing this post yesterday).

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Forcing re-entry of patient ID cuts wrong-patient errors

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You know how websites make you double enter your email address and password when you sign up for a service? Well, apparently that’s not a bad system for making sure you have the right patient during order entry. You’d think we would have figured that out a while back, but then again this is healthcare … Read more

Prenteral nutrition error [from #ISMP]

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From the latest ISMP Medication Safety Alert!, a mix up between an adult parenteral nutrition (PN) template in an electronic health record (#EHR) and one for pediatrics.

The big difference between these two is how you order electrolytes; it’s a really big difference.

The most shocking part of all this was that the error made it’s way through the physician that ordered it, a pharmacist that “entered the PN order” (I’m assuming in the compounding application), the “trained technician” that prepared it – missing the fact that the bag contained a whooping 2600mL of sterile water, the pharmacist that checked it, and finally the nurse that hung it. Swiss cheese anyone?

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Warning labels on outpatient prescription vials not so great after all

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Everyone has seen them, I know you have. Those little colored labels that the pharmacy slaps on your bottle when you get a prescription: “May cause drowsiness”, “Avoid excess sun”, “Do not take aspirin products without doctor approval” and so on. There are a ton of them. I remember seeing them lined up in front of me when I was working retail. Sometimes it became a game to see how many you could fit on the bottle without covering up valuable information for the patient. I’ve also been in pharmacies where the warning labels were simply printed alongside the medication label.

Well, it appears that this tradition may not be the best way to warn patients about potential issues with their medication. I mean, who really reads those things anyway?

A small study recently published in the journal PLoS ONE took a look at these warning labels and determined that people really don’t pay attention. Not surprising.

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