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Don't let emergency patients be harmed by unsafe storage of meds
Careless storage by ED nurses puts patients at risk
To control a patient's blood pressure, an ED nurse began an infusion with a bag of dopamine from an automated dispensing cabinet (ADC), but the nurse failed to realize that instead of the usual concentration of 400 mg/250 mL, the bag contained 400 mg/500 mL that had accidentally been stocked there. Since the nurse thought the maximum dose of dopamine already was being given, other measures were taken to maintain the blood pressure. The patient arrested and couldn't be resuscitated.1
Dopamine is one of the top 10 drugs involved in medication errors involving ADCs, according to the U.S. Pharmacopoeia — Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. To prevent these errors, the ISMP recommends using a standard concentration of dopamine, bar-code technology, and a double-check process. The above case illustrates the devastating impact improper storage can have in the ED.
In addition, surveyors from The Joint Commission are looking closely at medication safety in the ED. "The Joint Commission has definitely impacted how we store medications for a number of reasons," says Tracy Stark, RN, education coordinator for the Emergency Trauma Center at St. John's Health System in Springfield, MO.
"In the old days, we had medication bins of the most commonly used drugs," Stark says. "We took what was ordered, charted it, and then hopefully wrote it on the charge sheet." Now, medications are stored in an ADC, and there is nowhere else in the ED that medications can be found with the exception of the code cart, says Stark.
To reduce risks involved with storage of medications in the ED, do the following:
• Audit your ED's ADC.
At St. John's, the ADC is audited each morning by members of the pharmacy staff and, if they see a consistent discrepancy, then that medication becomes one the nurse must count back.
"This can include aspirin and bags of saline," says Stark. "After the count is done for a specified amount of time, then we no longer have to do a count-back, except for narcotics."
If a count-back is not correct for a narcotic, the nurse puts the correct number in, and then the charge nurse has to resolve the discrepancy by determining who the last user was, says Stark. Most of the time, it is an error in count-back quantity. "The charge nurses check this every 12 hours, or sooner if they notice a problem," says Stark. "If it is a medication that is not a narcotic, such as aspirin or [ondansetron], the same attempt to follow up is made."
• Secure drugs on code carts.
At Lacrosse, WI-based Franciscan Skemp Healthcare, even medications kept on code carts are packaged in a secure wrap and stored in a locked drawer, says Barbara Sue McBride, RN, patient care director of the emergency and urgent care departments. "When used, the whole tray goes back to pharmacy, and medications are checked," McBride says. "A tag is placed on the outside of the cart with the date of the first drug to expire, and nursing keeps an eye on that."
• Have a "one-use-only" practice.
St. John's formerly kept open medications in the cabinet, and members of the staff would get multiple uses from medications such as acetaminophen bottles, nitroglycerin tabs, and even insulin in the refrigerator, says Stark. Now every medication is packaged for one dose, or if a vial is used, it is mandatory that it is opened, used, and any remainder returned to pharmacy or wasted, says Stark. Here are the steps taken by ED nurses:
• Give staff training.
At Trident Medical Center in Charleston, SC, nurses and patient care technicians take mandatory courses in medication security, given by ED educators, who based the content on the hospital's policy and requirements from The Joint Commission, says Mindi Huckabee, RN, BSN, CEN, director of emergency services.
The courses are all computer-based, so nurses can complete a self-study module and post-test whenever it's convenient for them, says Huckabee. "The educational module and test cover the importance of medication security including intravenous [IV] fluids and the steps to take to ensure the correct procedures are being followed," she says. For example, the course reviews the process for opening a medication storage room for environmental services to clean the floor or take out the trash.
"This needs to be done in the presence of trained, authorized staff," says Huckabee. "The environmental services staff should not ever be left in the room alone."
• Use swipe badges to lock down all storage areas.
At Trident, ED nurses use key pads to access all supply rooms, but swipe badges are being implemented so that only specific individuals will have access, says Huckabee. In addition, doors are being installed to secure the medication area, which is in the middle of the nursing station.
"Although it is very obvious when someone is in the area that should not be, we want to lock the entire room down," says Huckabee. "We use the AcuDose system [McKesson Corp.; Cranberry Township, PA] for medication storage, but in order to comply with IV fluids being secure, the doors and swipe badges systems are being added."
If the area is open to the public there is always a risk that someone could tamper with the medications or fluids, explains Huckabee. "By restricting access to the storage areas, it automatically increases the safety for the patients," she says.
• Check for outdated medications.
Pharmacists at Trident check the ADC and refrigerators in the ED routinely for expired medications, says Huckabee. All crash carts have a card attached to the front stating "first drug to expire" with the name of drug and the date of expiration, so the cart does not have to be routinely opened to check for the expiration dates, she adds.
ED nurses complete an occurrence report for any expired medication that is found, documenting what medication they found, the location, and any information regarding how the medication may have been missed during routine checks, says Huckabee. "The pharmacy will follow up in collaboration with me when necessary, to complete any staff education that needs to occur," she says.
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