Ainara Campino1, Beatriz Sordo1, PIlar Pascual1, Casilda Arranz2, Elena Santesteban3, Maria Unceta4, Ion Lopez-de-Heredia2. 1. Hospital Pharmacy, Cruces University Hospital, Barakaldo, Spain. 2. Neonatal Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Barakaldo, Spain. 3. Hospital Biochemistry Laboratory, Cruces University Hospital, Barakaldo, Spain. 4. Neonatal Epidemiology Unit, Cruces University Hospital, Barakaldo, Spain.
Abstract
OBJECTIVE: The key objective of this study was to highlight the weak points in the medicine use process. METHOD: We collected 15 videos from eight neonatal intensive care units where staff nurses showed how medicine preparation was performed. Recorded medicines were: vancomycin (6), gentamicin (5), caffeine citrate (2) and phenobarbital (2). RESULTS: We did not review any video without errors. In 8/15 (53.3%) videos, the same syringe was used to measure the medicine and the diluent. In 8/15 (53.3%) videos, the syringes used were not the correct size for the volume being measured. In 4/15 (26.6%) videos, the volume measured into the syringes was not checked after it was measured from vials or ampoules. In just one vancomycin preparation could the reconstitution process be described as a correct process; in the other five videos, mixing after diluent addition to the vancomycin vial was almost non-existent (less than 10 s). Mixing after the medicine and diluent were in the same syringe was also non-existent in all of the videos. CONCLUSIONS: Hospitals should provide training programmes outlining the correct preparation technique.
OBJECTIVE: The key objective of this study was to highlight the weak points in the medicine use process. METHOD: We collected 15 videos from eight neonatal intensive care units where staff nurses showed how medicine preparation was performed. Recorded medicines were: vancomycin (6), gentamicin (5), caffeine citrate (2) and phenobarbital (2). RESULTS: We did not review any video without errors. In 8/15 (53.3%) videos, the same syringe was used to measure the medicine and the diluent. In 8/15 (53.3%) videos, the syringes used were not the correct size for the volume being measured. In 4/15 (26.6%) videos, the volume measured into the syringes was not checked after it was measured from vials or ampoules. In just one vancomycin preparation could the reconstitution process be described as a correct process; in the other five videos, mixing after diluent addition to the vancomycin vial was almost non-existent (less than 10 s). Mixing after the medicine and diluent were in the same syringe was also non-existent in all of the videos. CONCLUSIONS: Hospitals should provide training programmes outlining the correct preparation technique.
Entities:
Keywords:
Accuracy; Medication errors; Medicine preparation; Neonatal intensive care unit; Preparation errors
Authors: M Muñoz Labián; C Pallás Alonso; J de La Cruz Bertolo; M López Maestro; M Moral Pumarega; A Belaustegui Cueto Journal: An Esp Pediatr Date: 2001-12
Authors: A Campino Villegas; María C López Herrera; M García Franco; I López de Heredia Goya; A Valls i Soler Journal: An Pediatr (Barc) Date: 2006-04 Impact factor: 1.500
Authors: Christopher S Parshuram; Geraldine Y T Ng; Tommy K L Ho; Julia Klein; Aideen M Moore; Desmond Bohn; Gideon Koren Journal: Crit Care Med Date: 2003-10 Impact factor: 7.598