Medication Safety Watch - Issue 4, November 2012 - Hqsc.govt.nz

Medication Safety
Watch
Issue 4 – November 2012
Maintaining the cold chain for medicines
Current problem
Medication Safety Watch
A bulletin for all health
professionals and health care
managers working with medicines
or patient safety.
Key messages
• Maintaining the cold chain for
medicines
• National patient safety
campaign announced
• New medication safety
resources available
• Weight-based dosing
Contact details:
Nirasha.Parsotam@hqsc.govt.nz
Ph: +64 9 580 9144
Medication alerts
These alerts provide information
and required actions about
high-risk medicines and
situations and are issued to
health care staff, managers
and organisations. For more
information, contact Beth Loe at
Beth.Loe@hqsc.govt.nz.
OVERDUE: Oral Methotrexate
Alert Action Plan from DHBs
was due 30 October 2012.
Available from: http://www.
hqsc.govt.nz/our-programmes/
medication-safety/projects/
alerts/.
Staff reported fridge still not between 2°C and 8°C. Discovered that during the
previous three months, fridge had frequently been too warm but had also been
too cold. On three separate occasions, the temperature had been below 0°C.
Action taken
Stock removed and quarantined in fridge. Checked the stability of the
quarantined medicines with pharmacy. Staff told to obtain medicines from
another area or order from pharmacy when required. New pharmaceutical
grade fridge ordered. Value of stock currently quarantined $4,332.96.
Sound familiar
To maintain medicine integrity, temperature sensitive medicines such as insulin and
vaccines, require storage at a controlled temperature (2–8°C) with protection from
freezing. Deviations outside this temperature range can compromise medicine
efficacy, resulting in therapy failure or adverse events. It can also result in
unnecessary wastage of medicines, representing considerable financial loss to an
organisation over time.
Medicines are often stored in domestic fridges, which are designed to sustain a
temperature between 0–10°C. Domestic fridges are not usually recommended
because they don’t have the precise electronic control necessary to maintain the
temperature within the required range of 5±3°C. For example, at 0°C vaccines
can freeze and become deactivated. At temperatures above 8°C, their potency
may be compromised.
Fridges specifically designed
for the storage of medicines
are calibrated to ensure a
temperature within the range
2–8°C. Forced air circulation
ensures a uniform temperature
across the cabinet as well as
giving rapid cool-down after
the door has been opened. Fridges used to store medicines should not contain
an ice box. The presence of an ice box increases the chances of items freezing
despite the fridge remaining within the desired temperature range of 2–8°C.
For information on maintaining the cold chain, go to http://www.immune.org.
nz/health-professionals/cold-chain or http://www.health.govt.nz/publication/
national-guidelines-vaccine-storage-and-distribution-2012. 1 While the
guidelines focus on vaccines, they apply to all medicines requiring storage within
the range 2–8°C.
continued on next page
1. Ministry of Health. 2012. National Guidelines for Vaccine Storage and Distribution. Wellington: Ministry of Health.
The information in this bulletin is believed to be true and accurate. It is issued on the understanding that it is the best available information at the time of issue.
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Medication Safety Watch
continued from page 1
Medication safety tips
1. Designate someone to be responsible for the medicine fridge or add it to a
checklist that a manager sees daily.
2. Minimise the stock kept in medicine fridges.
3. Ensure medicine fridges are permanently wired in place to prevent accidental
disconnection and are on essential power supply in case of power failure.
4. Leave medicines in their original packaging and ensure there is adequate
airflow around the medicines stored in the fridge.
5. Review temperature charts daily and act immediately when an out-of-range
temperature is detected.
6. Tell your patients to store their medicines in the middle of their fridge at home,
not in the door or back of the fridge.
What’s new
National patient safety campaign
The goal is safe, quality health care –
every day, every time. The Health Quality
& Safety Commission will work with the
sector to reduce harm in these four areas;
falls, medication errors, surgery and
health care associated infections. Initially,
the focus will be on proven improvements
in the hospital setting that complement
providers’ existing quality and safety
strategies. For more information, see
http://www.hqsc.govt.nz/nationalpatient-safety-campaign/.
SafeRx is an initiative by the Quality Use
of Medicines (QUM) Team at Waitemata
District Health Board. The website,
www.saferx.co.nz, contains resource
materials designed for health professionals
working in primary care to promote the safe
and effective use of high-risk medicines.
New medication safety resources
Incidents and cautions
Paracetamol toxicity
A community patient was receiving her
‘when required’ paracetamol tablets
via a blister pack supported by a home
support worker. The patient unintentionally
overdosed on the tablets left with her to
self-administer. She suffered hepatic and
renal failure and died after eight days in
hospital. Consider limiting the supply of
‘when required’ medicines that are left
with a patient for self-administration to
24 hours worth.
Look and sound alike generic
medicines
The Commission continues to receive
reports of look-alike generic medicines
(see images below) and is pursuing these
with the stakeholders involved. Minimise
the risk of an error by storing such
identified medicines out of order or in an
alternate location.
Weight-based dosing
When the dose of a medicine is
dependent on the patient’s weight (eg,
with enoxaparin), you need to check the
weight you use is accurate and current.
Estimation is risky and can result in patient
harm. Document the weight used for
dosing on the order or prescription so
the dose can be checked by others.
Upcoming events
• 5th International Medication
Safety Network Medication Safety
Conference, 15–17 November
2012 Abu Dhabi, UAE http://www.
medicationsafetyconference.com/
index.aspx
Ask a pharmacist before you
crush or split oral dose forms.
Crushing, chewing, cutting or
diluting certain oral medicines
may destroy the intended effect
of the medicine and may cause
an adverse event.
Contribute to Medication
Safety Watch
Are you or your organisation
working on a new medication
safety initiative Has there been a
medicine-related incident or error
that has happened that you would
like to warn others about If so,
please contact:
Nirasha.Parsotam@hqsc.govt.nz
Check out the Commission link http://
www.hqsc.govt.nz/our-programmes/
medication-safety for new medication
safety resources, including Version 3 of the
Standards and two short New Zealand
videos featuring hospital staff on medicine
reconciliation and the medication chart.
www.hqsc.govt.nz
The information in this bulletin is believed to be true and accurate. It is issued on the understanding that it is the best available information at the time of issue. 2