New solutions to reduce wrong route medication errors

Local anesthetic systemic toxicity (LAST) is a life-threatening adverse event that may occur after the administration of local anesthetic drugs through a variety of routes. Increasing use of local anesthetic techniques in various healthcare settings makes contemporary understanding of LAST highly relevant. Recent data have demonstrated that the underlying mechanisms of LAST are multifactorial, with diverse cellular effects in the central nervous system and cardiovascular system. Although neurological presentation is most common, LAST often presents atypically, and one-fifth of the reported cases present with isolated cardiovascular disturbance. There are several risk factors that are associated with the drug used and the administration technique. LAST can be mitigated by targeting the modifiable risk factors, including the use of ultrasound for regional anesthetic techniques and restricting drug dosage. There have been significant developments in our understanding of LAST treatment. Key advances include early administration of lipid emulsion therapy, prompt seizure management, and careful selection of cardiovascular supportive pharmacotherapy. Cognizance of the mechanisms, risk factors, prevention, and therapy of LAST is vital to any practitioner using local anesthetic drugs in their clinical practice.

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“…The transition from Luer connectors to new ISO 80369 standard small-bore connecters might also reduce the risk of wrong route injection. 77 , 78 …”

Section: Preventionmentioning

confidence: 99%

Local anesthetic systemic toxicity: current perspectives

El‐Boghdadly¹,

Pawa²,

Chin³

2018

LRA

355

269

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“…accidental administration of an enteral solution through the intravenous route), the California State Assembly passed bill 444. 20,21 This bill, which came about through the lobbying efforts of the California Hospital Patient Safety Organization, prohibits enteral and neuraxial connections to be compatible with intravenous connections. In theory, once manufacturers switch over to unique types of route-specific connectors that cannot be used interchangeably, they will phase out all preexisting universally compatible connectors, and the newer, safer connection will become the standard of care.…”

Section: Existing Laws and Regulations That Govern Medication Adminismentioning

confidence: 99%

Use of a public health law framework to improve medication safety by anesthesia providers

Litman

2019

Journal of Patient Safety and Risk Management

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Medication administration by anesthesia providers in the perioperative environment is a uniquely risky endeavor because the prescribing clinician is the same person that dispenses, premixes, repackages, relabels and administers the medications, independently without secondary verification or use of technologic support. Two important sources of medication error by anesthesia providers include vial swap and syringe swap. Currently, there exist potential ways to prevent these types of errors, but few hospitals have implemented these solutions because of cost and availability. They include the use of prefilled drug syringes, which will greatly reduce preparation from the wrong drug vial, and bar-coding of these syringes prior to administration, which will likely reduce the incidence of administering the wrong drug syringe. If harm from medication errors can be considered within the sphere of "public health," then the use of a public health law framework may decrease the incidence of medication errors by anesthesia providers and increase patient safety.

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“…As the new standards for small‐bore connectors for medical use were issued by the ISO in September 2016, the current slip‐in type D port (ISO8637) will be changed to the Luer lock type (ISO80369‐7), with the agreement of both medical professionals and members of MTJAPAN . To complete this modification of the plasma separator D port, another issue that will inevitably be caused by the shape change has to be resolved.…”

Section: Efforts To Change the Shape Of The Dialysate Port Of Plasma mentioning

confidence: 99%

Modification of the Dialysate Port of Plasma Separators for Safe Blood Purification in Japan

et al. 2019

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A fatal mix‐up of a hemofilter with a plasma separator occurred in 2011. The close resemblance between the two blood purification columns commonly used in Japan posed a fundamental risk for such mix‐ups. Both the in‐hospital case investigation committee and the relevant academic societies have independently proposed the modifications of the dialysate port (D port) of the plasma separator to avoid this type of misuse. To make these devices foolproof, medical professionals, including physicians and clinical engineers, and members of the Medical Technology Association of Japan discussed measures to prevent this type of recurrence. Since new standards were soon to be issued by the International Organization for Standardization (ISO), the modifications were temporarily postponed. In September 2016, the ISO released new standards for small‐bore connectors. The shape changes of the D port from the current slip‐in type (ISO8637) to the Luer lock type (ISO80369‐7) had been already approved by the Ministry of Health, Labor and Welfare of Japan by the end of November 2018, including a temporal use of a converter to connect the current type of D port to the new type of blood circuit. We must address the next issue that the new standard and the older standard coexist in the clinical setting, which may create a new risk.

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New solutions to reduce wrong route medication errors

Abstract: SummaryWrong route medication errors due to tubing misconnections are potentially life-

Cited by 18 publications

References 16 publications

Local anesthetic systemic toxicity: current perspectives

Local anesthetic systemic toxicity: current perspectives

Use of a public health law framework to improve medication safety by anesthesia providers

Modification of the Dialysate Port of Plasma Separators for Safe Blood Purification in Japan

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