Overview: Patients on labor and delivery units have mistakenly received high doses of narcotics instead of IV antibiotics, due to look-alike infusion bags and overlooked warning labels. This can lead to death, seizures and respiratory arrest.
What you can do: Follow 12 precautions outlined by the ISMP.
Patients on labor and delivery have mistakenly received high doses of narcotics instead of IV antibiotics, due to look-alike infusion bags and overlooked warning labels, the Institute for Safe Medication Practices (ISMP) warns.
The recent drug shortage of bupivacaine and 100 mL bags of 0.9% sodium chloride contributed to the errors, as well as user errors associated with point-of-care barcode medication administration systems.
12 preventive measures you can take
- Initiate and verify orders.
- Consider less toxic anesthetics.
- Inform all practitioners when products or preparation processes change due to drug shortages or other reasons.
- Use a different size or shape container, or colored overwraps, for epidural analgesia to differentiate it from IV medications and infusions.
- Apply distinctive, large warning labels that state, “For Epidural Use Only,” in a standard color on both sides of an epidural analgesia bag.
- Have pharmacy dispense epidural analgesia along with the required yellow-striped epidural tubing to promote administration by the correct route.
- Scan each epidural infusion individually before placing it in the correct storage location (when technology allows).
- Define “patient readiness.”
- Limit access to epidural analgesia.
- Reduce interruptions.
- Establish an admission process that ensures L&D patients have a barcoded ID band applied shortly after arrival and before non-emergent medications or solutions are administered. Conduct a time-out.
- Trace lines from their respective sources (and infusion pump) to the patient’s access into the body before making connections or administering medications or solutions.