Patient Safety WHO collaborative High 5s topics . Prevention of patient care hand-over errors Prevention of wrong site/wrong procedure/wrong person surgical errors Accurate medicines reconciliation Prevention of high concentration drug errors Promotion of effective hand hygiene practices .
“worldwide evidence that concentrated injectable medicines have been involved in medication incidents resulting in death or serious harm”
Usage of KCl ampoules = ??? p.a.
Essential areas (ICU CCU ED) = ??p.a.
X reported incidents at XDHB in last 6 months and 1 nationally, all potentially serious.
Action taken already:
KCl concentrate ampoules stored securely on X wards in XX
DHBNZ Audit 2009
X x KCl premixes in use = XX p.a
Protocols rationalised to X documents (ICU & Adult)
Add 3 more pre-mix bags over next 12 months and remove ampoules from all but essential clinical areas.
1. 10mmol KCl in 10% Glucose 500ml (GIK):
3. Paediatric bag 500ml:
By adding 2 more premix bags, 1 x GIK, 1x N/S with KCl 40mmol to stock a total of 4 premixes.
XDHB would expect:
The Productive Ward