Resist temptation to pre-pour medications: ISMP Canada

What do these incidents have in common? A medication cup with opioid tablets was left at the bedside of a patient recovering from surgery. The patient was told to take the medication when they were in pain and then tell the nurse they had taken it. When the cup was empty, it was re-filled. The patient took too many, fell unconscious and needed fluid resuscitation thanks to hypotension from the opioids. A nurse prepared a syringe of propofol and left it on the bedside of a patient who was in intensive care, intubated and ventilated. When the patient became agitated, an IV push dose of propofol was ordered, and the patient was given the syringe that was beside them. However, when the propofol was administered, the patient was oversedated. It was later discovered that the syringe had been labelled with the incorrect dose, leading to a ten-fold error. An antipsychotic medication was mixed into milk for a long-term care resident and then accidentally given to another. All three are connected by their root cause: pre-pouring medications for patients. ISMP Canada (ISMPC) defines pre-pouring as a delay between preparing and administering medication, or preparing multiple medications for different clients. Doing this can be tempting because it seems more efficient, the institute says, but it can cause risks to patient safety. Pre-pouring isn’t a new issue—ISMPC has brought it up before—but a recently reported cluster of incidents, including those described above, show that it continues to happen. Read: Dexamethasone oral liquid confusion leads to underdose in infant: ISMP CanadaPre-pouring created multiple risks, ISMPC said in a recent safety bulletin. It often means that the medication is removed from its packaging, which identifies the medication and the patient it's intended for. It prevents confirmation of the medication and dose against the medication administration record just before the medication is given to the patient. And it can cause delayed or inaccurate documentation. There’s also an increased risk when pre-poured medications are available for patients to self-administer without a clear protocol. And there’s the added risk of contamination through things like pre-drawn syringes. Finally, it makes the accountability for administering medication safely more confusing because it could go to the person preparing the medication or the one administering it to the patient. And it could also make diversion more likely. Read: Changing packaging regulations could reduce acetaminophen overdoses: ISMP CanadaSeveral Canadian provincial nursing regulatory bodies specifically say nurses should avoid pre-pouring medications, and most provincial regulatory authorities expect members to prepare medications just before administration. ISMPC recommends that nurses discard any medications prepared in a syringe at the end of their shifts and incoming nurses discard any that others have prepared when they start their shifts. Nurses should prepare and administer medications for one patient at a time and prepare them just before administering them so that they can check the original product and MAR, check the patient’s ID, and document the medication promptly. When more than one nurse does have to prepare and administer a medication—which happens in an emergency—one nurse should prepare and label the medication, and the other nurse should administer it after an independent double-check. (Some nursing bodies mandate that both nurses document in the health care record in these cases.) Healthcare organizations also have a responsibility to address pre-pouring. They should have policies that describe acceptable situations for multiple nurses to prepare and administer medications, such as cardiac arrests. And they should see the pre-pouring of medications in regular situations as a chance to work through the issues leading to the workaround. Cognitive walkthroughs and other proactive approaches can help organizations identify the risks of this and develop solutions. Read: Watch those units of measurement: Mistakes with compounded clonidine products send children to hospital: ISMP Canada

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