Medication Safety & Quality Improvement PDF

76 | MEDICATION SAFETY & QUALITY IMPROVEMENT Look -alike, sound -alike medications should be stored in different locations within the ADC. Using computerized alerts, ideally pop- up alerts that require a confirmation when medications with high potential for mix- up in a given setting are selected ,...

76 | MEDICATION SAFETY & QUALITY IMPROVEMENT Look -alike, sound -alike medications should be stored in different locations within the ADC. Using computerized alerts, ideally pop- up alerts that require a confirmation when medications with high potential for mix- up in a given setting are selected , can help reduce error risk. Certain medications should not be put into the ADCs, including insulin, warfarin and high -dose narcotics (such as hydromorphone 10 mg / mL and morphine 20 mg / mL). Nurses should not be permitted to put medications back into the medication compartment because it might be placed in the wrong area; it is best to have a separate drawer for all "returned ” medications. If the machine is in a busy, noisy environment, or in one with poor lighting, errors increase. PATIENT CONTROLLED ANALGESIA DEVICES Opioids are effective agents used for moderate to severe post - surgical pain and are the mainstay of treatment. These may be administered with patient controlled analgesia ( PCA ) devices. PCAs allow the patient to treat pain quickly ( there is no need to call the nurse and wait for the dose to arrive) and allow the administration of small doses, which helps reduce side effects ( particularly over -sedation). PCA drug delivery can mimic the pain pattern more closely and provide good pain control. Increasingly, the PCA is administered with anesthetics for a synergistic benefit in pain relief. PCA Safety Considerations The devices can be complex and require set - up and programming. This is a significant cause of preventable medication errors. PCAs should be used only by well coordinated healthcare teams. not be Patients may appropriate candidates for PCA treatment. They should be cooperative and should have a cognitive assessment prior to using the PCA to ensure that they can follow instructions. Friends and family members should administer not PCA doses. This is a TIC requirement. PCAs do not frequently cause respiratory depression, but the risk is present. Advanced age, obesity and concurrent use of CNS depressants (in addition to higher opioid doses) increases risk. PCA Safety Steps Limit the opioids available in floor stock. Use standard order sets (set drug dosages, especially for opioid - naive patients) so that drugs are not over -dosed. Educate staff about HYDROmorphone and morphine mix - ups. Implement PCA protocols that include independent double-checking of the drug, pump setting, and dosage. The concentration on the MAR should match the PCA label. Use barcoding technology. Some infusion pumps incorporate barcoding technology. Scanning the barcode on the PCA would help ensure the correct concentration is entered during PCA programming. It will also ensure that the right patient is getting the medication. Assess the patient’s pain , sedation and respiratory rate on a scheduled basis. INFECTION CONTROL IN HOSPITALS Nearly two million infections occur in hospitals annually - about one infection for every twenty patients. Hospital infections cause avoidable illness and death and add enormous financial costs. Many of these infections are preventable if proper techniques are followed. Many states now require hospitals to report infection rates and Medicare can refuse reimbursement for hospital -acquired infections that are largely avoidable. It is important to properly clean surfaces, including bed rails, eating trays and other room surfaces. Healthcare professionals should be careful not to be sources of infection from contaminated clothing ( including white coats and ties). Organisms that spread via surface contact include VRE , C. difficile , noroviruses and other intestinal tract pathogens. COMMON TYPES OF HOSPITAL- ACQUIRED (NOSOCOMIAL) INFECTIONS infections from indwelling catheters ( very ) common . Remove the catheter as soon as possible preventing catheter associated infections is one of TJC's Urinary tract NPSGs. Blood stream infections from IV lines (central lines have the highest risk ) and catheters Surgical site infections (see the Infectious Diseases II chapter) Decubitus ulcers Hepatitis Clostridium difficile , other GI infections Pneumonia ( mostly due to ventilator use ) , bronchitis RxPrep Course Book | RxPrep <D2019, RxPrep C 2020 ' UNIVERSAL PRECAUTIONS TO PREVENT TRANSMISSION Universal precautions is an approach to infection control that treats human blood and bodily fluids as if they are known to be infectious for HIV, HBV and other bloodborne pathogens. Contact with bodily fluids should be avoided through the use of good hand hygiene and, in select cases, the use of gowns, masks or patient isolation. There are three categories of transmission - based precautions defined by the CDC: Contact Precautions Intended to prevent transmission of infectious agents which are spread by direct and indirect contact with the patient and the patient's environment. Single patient rooms are preferred. If not available, keep > 3 feet spatial separation between beds to prevent inadvertent sharing of items between patients. Healthcare personnel caring for these patients wear a gown and gloves for all interactions that may involve contact with the patient or contaminated areas in the patient 's room. Contact precautions are recommended for patients colonized or infected with MRSA and VRE and patients with C. difficile infection. Droplet Precautions Intended to prevent transmission of pathogens spread through close respiratory contact with respiratory secretions. Single patient rooms are preferred . If not available, keeping > 3 feet spatial separation and drawing a curtain between beds is especially important for diseases transmitted via droplets. Healthcare personnel wear a mask (a respirator is not necessary ) for close contact with the patient. The mask is donned upon entry to the patient's room. Droplet precautions are recommended for patients with active B. pertussis , influenza virus, respiratory syncytial virus ( RSV ) , adenovirus, rhinovirus, N . meningitidis , and group A streptococcus ( for the first 24 hours of antimicrobial therapy) . Airborne Precautions Intended to prevent transmission of infectious agents that remain infectious over long distances when suspended in the air. Patient should be placed in an airborne infection isolation room (AIIR ). An AIIR is a single - patient room that is equipped with special air and ventilation handling systems. The air is exhausted directly to the outside or re -circulated thmnah HF.PA filtration before being returned. Healthcare personnel wear a mask or respirator ( N 95 level or higher ) , depending on the disease, which is donned prior to room entry. Airborne precautions are recommended for patients with active pulmonary tuberculosis, measles or varicella virus (chickenpox ) . CATHETER- RELATED BLOODSTREAM INFECTIONS The most important and most cost-effective strategy to minimize catheter - related bloodstream infections (CRBSl ) is through aseptic technique during catheter insertion, including proper handwashing and utilization of standard protocols /catheter insertion checklist. It is also important to minimize use of intravascular catheters, if possible, through intravenous to oral route protocols and setting appropriate time limits for catheter use. For example, peripheral catheters should be removed / replaced every 2 - 3 days to minimize risk for infection. Other strategies shown to reduce the risk of CRBSl , include the use of skin antiseptics ( 2% chlorhexidine) , antibiotic impregnated central venous catheters, and antibiotic / ethanol lock therapy, but must be weighed against the potential risk for increased rates of resistance. HAND HYGIENE Numerous studies show that proper hand hygiene by those working in healthcare settings reduces the spread of nosocomial infection. Alcohol - based hand rubs (gel , rinse or foam ) are considered more effective in the healthcare setting than plain soap or antimicrobial soap and water, but soap and water are preferable in some situations. Fingernails should be clipped short and no jewelry should be worn under gloves ( this can harbor bacteria and tear the gloves) . Antimicrobial hand soaps that contain chlorhexidine ( Hibiclens , others) may be preferable to reduce infections in healthcare facilities. Triclosan may also be better but this compound gets into the water supply and has environmental concerns. . 76 | MEDICATION SAFETY 6 QUALITY IMPROVEMENT When to Perform Hand Hygiene Before entering and after leaving patient rooms and between patient contacts if there is more than one patient per room. Before donning and after removing gloves ( use new gloves with each patient ). SAFE INJECTION PRACTICES FOR HEALTHCARE FACILITIES Never administer an oral solution/suspension intravenously, fatal errors have occurred. Use oral syringes (which are difficult or impossible to attach to a needle for IV injection) and label oral syringes “ for oral use only.' 1 CDC / Amando Mills invasive Before handling , devices including injections. After coughing or sneezing. Before handling food and oral medications. Use Soap and Water (not Alcohol- Based Rubs) in These Situations Before eating. After using the restroom. Anytime there is visible soil (anything noticeable on the hands) . After caring for a patient with diarrhea or known C. difficile or spore -forming organisms; alcohol - based hand rubs have poor activity against spores. Handwashing physically removes spores. Before caring for patients with food allergies. Soap and Water Technique Wet both sides of hands, apply soap, rub together for at least 15 (slow ) seconds. Rinse thoroughly. Dry with paper towel and use the towel to turn off the water. Alcohol- Based Hand Rubs Technique Use enough gel ( 2 - 5 mL or about the size of a quarter ). Rub hands together until the rub dries (15 - 25 seconds ). Hands should be completely dry before putting on gloves. Hand- Hygiene for Sterile Compounding Refer to the Compounding chapters. SAFE INJECTION PRACTICES i Outbreaks involving the transmission of blood borne pathogens (e.g., HIV, hepatitis B or C) or other microbial pathogens to patients (and occasionally to healthcare workers) continue to occur due to unsafe injection technique. The majority of safety breaches involve the reuse of syringes in multiple patients, contamination of IV bags with used syringes, failure to follow basic injection safety when administering IV medications and inappropriate car Never reinsert used needles into a multiple- dose vial or solution container. Single- dose vials are preferred over multiple- dose vials, especially when medications will be administered to multiple patients. Needles used for withdrawing blood or any other bodily fluid, or used for administering medications or other fluids should preferably have "engineered sharps protection" which reduces the risk of an exposure incident by a mechanism such as drawing the needle into the syringe barrel after use. Never touch the tip or plunger of a syringe. Disposable needles that are contaminated (e.g., with drugs, chemicals or blood products) should never be removed from their original syringes, unless no other option is available. Throw the entire needle/syringe assembly (needle attached to the syringe) into the red plastic sharps container. Immediately discard used disposable needles or sharps into a sharps container without recapping . Sharps containers should be easily accessible and not allowed to overfill; they should be routinely replaced. or maintenance of glucometer equipment that is used on multiple patients. If a needle -stick ( percutaneous exposure) occurs with a used needle, contact the proper department at a healthcare facility immediately. If post exposure prophylaxis ( PEP) is required (for HIV and /or hepatitis) , acting quickly is important. In the outpatient setting, instruct the patient to wash the area right away with soap and water, and contact their healthcare provider. See Human Immunodeficiency Virus chapter for details on PEP medication regimens. SHARPS DISPOSAL Patients who use injectable medications should have a disposal container and be instructed to put needles and other sharps in the container immediately after use. Sharps should be disposed of in an FDA-cleared sharps container, which is puncture resistant, labeled or color- coded appropriately, closeable and leak - proof. They come marked with a line that indicates when the container should be considered full (about V* full ). Never compress or “ push down” on the contents of any sharps container. If an FDA-cleared container is not available, some community guidelines recommend using a heavy-duty plastic household container as an alternative (e.g., a plastic laundry detergent container ). The container must be leak and punctureresistant with a tight -fitting lid. RxPrep Course Book | RxPrep © 2019, RxPrep © 2020 The entire needle /syringe assembly is discarded. Do not instruct patients to remove the needle or attempt to cut it. The only time that recapping a needle is permitted is when the sharps container is not immediately available; in that case, use the one - hand method to recap until the sharps container can be reached: ( l ) Place the cap on a table or counter next to something firm to push the cap against; ( 2) Hold the syringe with the needle attached and slip the needle into the cap without using the other hand . Push the capped needle on the firm surface to "seat ” the cap onto the needle using only the one hand. Sharps disposal guidelines and programs vary. The local trash removal services or health department should have the available service /s, and the pharmacy can provide this information to patients. Services include drop boxes or supervised collection sites (such as in a hospital, pharmacy, police or fire station ) , household hazardous waste collection sites, mail - back programs and residential special waste services pick- up. Select Guidelines/References Institute for Safe Medication Practices, www.ismp.org (accessed 2019 Mar 6). The Joint Commission, www.jointcommission.org (accessed 2019 Mar 6). MMWR Guideline for Hand Hygiene in Health-Care Settings October . . 25 2002 51( RR 16);l-44.