1 / 23

CRRT Complications and Troubleshooting

CRRT Complications and Troubleshooting. Objectives. At the end of this presentation, the health care provider will be able to: List the potential errors associated with pharmacy prepared solutions Review actual errors associated with CRRT solutions that have occurred in different institutions

percy
Download Presentation

CRRT Complications and Troubleshooting

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CRRT Complications and Troubleshooting

  2. Objectives At the end of this presentation, the health care provider will be able to: • List the potential errors associated with pharmacy prepared solutions • Review actual errors associated with CRRT solutions that have occurred in different institutions • Apply the information to a case study

  3. Potential for Errors in CRRT • Physician errors when using non standard orders for dialysate or replacement solutions • Nursing administration errors in choice of solutions • Pharmacy transcription errors in dialysate orders • Pharmacy calculation errors in compounding • Pharmacy product selection errors in compounding

  4. NEED FOR STANDARD ORDERS

  5. Administration Errors • Confusion of calcium chloride infusion bags for sodium bicarbonate replacement solution bags • Labeling of calcium chloride infusion bags with bright fluorescent stickers by pharmacy • Separation of replacement fluids from calcium chloride bags in separate bins

  6. Administration Errors • Nursing mixed concentrated Normocarb dialysate with normal saline instead of sterile water • Pharmacy mixing of Normocarb?

  7. Dialysate Compounding Errors Foothills Medical Centre, Calgary Health Region • 83 yo female in CV ICU died suddenly in the presence of family and physicians • ICU physician suspected dialysate used for CRRT • An analysis of dialysate solutions revealed potassium chloride was used in place of sodium chloride • Attributed to another death that occurred one week prior

  8. Foothills Medical Centre, CHR • 3 liter bags prepared in batches of 36 bags • Dialysate concn Na 110 mEq/L, Mg 0.7 mEq/L • Prepared by 4 pharmacy technicians involved in setup and documentation, checking of setup, product transfer, final check • No empty bottle verification against worksheet • No pharmacist check of final product

  9. Foothills Medical Centre, CHR • At FMC, 34% of the pharmacy staff were pharmacists • National averages are 44% pharmacists • “Tech check tech” delegation endorsed by CSHP • Over delegation of pharmacist responsibilities?

  10. CHR Recommendations “The feasibility of using commercially prepared dialysate solutions be explored.” “When patient care issues necessitate that in-house manufacturing of complex preparations be undertaken, process mapping be used to simplify the processes as much as possible.”

  11. FDA Labeling Changes Death due to the accidental misadministration of concentrated KCl Injection led to: • Changing the official USP name to Potassium Chloride for Injection Concentrate (emphasis added) • Labels must now bear a boxed warning "Concentrate: Must be Diluted Before Use;" • The cap must be black in color (the use of black caps is restricted to this drug product only) • The cap must be imprinted in a contrasting color with the words, "Must be Diluted."

  12. Different Perspectives • According to ISMP survey, 91% nurses vs 98% pharmacists consider IV KCL to be a high alert medication • 73% nurses vs 94% pharmacists consider hypertonic sodium chloride inj to be a high alert medication

  13. Time Requirements • Pharmacy needs advanced notice to prepare dialysate, replacement fluids, calcium chloride, citrate infusions • Often the same patient requires pressors that need to be mixed by pharmacy • Daily rounding and ordering of solutions by ICU pharmacist to determine need

  14. USP 797 • Immediate Use Exemption from ISO Class 5 (Class 100) • Three or fewer sterile products may be prepared in worse than ISO Class 5 air when there is no direct contact contamination, and administration begins within 1 hour and is completed within 12 hours of preparation.

  15. USP 797 • Need for aseptic preparation? • IHD data on bicarbonate dialysate • Bacterial growth and endotoxin production • Sterile versus non sterile dialysate • IL 1 production • Interleukin hypothesis

  16. Water and Dialysate Quality

  17. Case Study • What happened? • Analysis of the replacement fluid revealed that the NaHCO3 was never placed in the solution and the total Na was 105 mEq/L

  18. Case Study • Root Cause Analysis • Why was sodium bicarbonate not added to the solution? • Are the replacement solutions prepared in batches or on a patient by patient basis? • What is the process for pharmacy set-up, preparation, final check and documentation? • Are the products and syringes made available for final check? • Is the pharmacist involved in checking the final product?

  19. Extemporaneous Compounded Solutions *mEq/L unless otherwise stated

  20. Comparison of Commercial Dialysate

  21. Recommendations • Use commercially available products whenever feasible • Standard physicians orders for CRRT solutions • Separate look alike drugs in the pharmacy • Ensure process for pharmacy prepared solutions is mapped out • Ensure pharmacist is the final check! • Training, training, training! • Label and separate solutions at the bedside in appropriate bins

More Related