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Aim
An in-depth review of an error involving the inadvertent administration of a
twenty-fold higher dose of metaraminol, due in part to the presence of two
metaraminol product concentrations (10 mg/1 mL vials and 3 mg/6 mL vials),
recommended keeping a single concentration in operating theatres. Using
forcing functions such as removing concentrated solutions associated with risk
is a more effective systems-focused intervention when compared with
education and training alone.1 To learn from medication incidents for system
wide improvement, this study aimed to implement a single concentration of
metaraminol throughout the organisation, to reduce the risk of future medication
errors.
Methods
The feasibility of complete removal of the 10 mg/1 mL metaraminol product from
Austin Health was tested in partnership with clinicians to ensure viability of a
product switch. Alternative products were assessed for quality of packaging and
labelling, product availability with secured supply chains, budget impacts and
potential wastage. Working closely with the Cerner Electronic Medical Records
(EMR) team, the intravenous order sets that display in the EMR were revised.
These were crucial to ensure the prescribing and documentation would be clear
and unambiguous on changeover day. A one-page summary was published on
the hospital intranet, together with signage and focussed communication to
medical, nursing and pharmacy staff.
Results
Prior to changeover day in October 2023, Austin Health had two concentrations
of metaraminol in operating theatres, recovery, emergency, intensive care unit
and selected procedural areas. The 10 mg/1 mL vials have been removed and
replaced with a pre-diluted vial containing 10 mg/ 20 mL. The changes were
made in Cerner EMR and infusion orders monitored to ensure a smooth and
safe transition.
Conclusion
Implementation of recommendations from incident reviews may protect
consumers and clinicians from administration errors related to wrong product
selection.
1. Soong C, Shojania KG. BMJ Qual Saf 2020; 29: 353-357 |
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