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 .
SOP - Management of
“worldwide evidence that concentrated injectable medicines have been involved in medication incidents resulting in death or serious harm”
Process Flow used for
What is the problem?KCl in Conc ampoule form can be fatal if not handled properly!
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):
2. 40mmol KCl in N/Saline 1000mL:
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:
From this to this!
The Productive Ward