Drug Error with Prepared Infusion in Intensive Care Unit by Staff
Drug infusions is drawn by a Registered Nurse and be used within own shift only. Most often Nurses draw-up drug infusion for the next shift and the incoming staff think this is great.
Preparing drug infusion for the next shift can be very dangerous. It is not advisable to use an infusion not present when it was drawn up as errors could have occured during dilution or wrong drug all together. Take for instance Noradrenaline could have been prepared in 50mls of 5% Dextrose and nicely labelled however, due to busy schedule of the Unit the Nurse may have forgotten to add the Noradrenaline to the infussion and the next shift uses this infusion what happens then? The patient blood pressure starts to drop and eveyone thinks why is the patient’s blood pressure dropping doctor will say go higher on the Noradrenaline and eventually prescribe fluid start dose but little would anyone knows that there is no Noradrenaline added to the infusion syringe. l have come across such incident whereby you just have to prepare a new infusion and connect to patient thereafter blood pressure and mean arterial pressure improve nicely to the parameter set by the Physician, or Neurologist, and Neurosurgeon and good perfusion observed. Failure of Noradrenaline can be detected when it failed to work what about other infusions.
Having attended the European Society of Intensive Care Medicine (ESICM) Conferences, it was said not to use a drawn up infusion that has been prepared by a colleague in your absent evidence based practice suggest safety of the patient is priority, staff, Unit and the Trust in question.
Personally do not use a drawn up infusion neither draw up one for the next shift. If an infusion is coming to an end towards the start of next shift, l will prepare the infusion connect to the patient, start the infusion and handover. This is to avoid a delay in treatment following clinical time judgement.
Drug infusion can be drawn-up shift by shift by so doing will not compromise patients safety, avoid drug error, and cost effective. Throwing away drawn-up infusions due to uncertainty becomes unnecessary wastage. Hospitals should implement actions to avoid drawn up infusions for the next shift or staff. This is not about lack of trust but it is all about safety measures for all.
European Society of Intensive Care Medicine 2015
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