Patient Safety WHO collaborative High 5s topics

1. Patient SafetyWHO 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. 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)

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